Coronary artery bypass graft surgery

August 21, 2004

--------------------------------------------------------------------------------


Main Search Index
Definition Purpose Precautions Description Preparation Aftercare Risks Terms Resources


Coronary artery bypass graft surgery

Coronary artery bypass graft surgery builds a detour around one or more blocked coronary arteries with a graft from a healthy vein or artery. The graft goes around the clogged artery (or arteries) to create new pathways for oxygen-rich blood to flow to the heart.

(Illustration by Electronic Illustrators Group.)




Definition

A surgical procedure in which one or more blocked coronary arteries are bypassed by a blood vessel graft to restore normal blood flow to the heart. These grafts usually come from the patient's own arteries and veins located in the leg, arm, or chest.

Purpose

Coronary artery bypass graft surgery (also called coronary artery bypass surgery, CABG, and bypass operation) is performed to restore blood flow to the heart. This relieves chest pain and ischemia, improves the patient's quality of life, and in some cases, prolongs the patient's life. The goals of the procedure are to enable the patient to resume a normal lifestyle and to lower the risk of a heart attack.

The decision to perform coronary artery bypass graft surgery is a complex one, and there is some disagreement among experts as to when it is indicated. Many experts feel that it has been performed too frequently in the United States. According to the American Heart Association, appropriate candidates for coronary artery bypass graft surgery include patients with blockages in at least three major coronary arteries, especially if the blockages are in arteries that feed the heart's left ventricle; patients with angina so severe that even mild exertion causes chest pain; and patients who cannot tolerate percutaneous transluminal coronary angioplasty and do not respond well to drug therapy. It is well accepted that coronary artery bypass graft surgery is the treatment of choice for patients with severe coronary artery disease (three or more diseased arteries with impaired function in the left ventricle).

Precautions

Coronary artery bypass graft surgery should ideally be postponed for three months after a heart attack. Patients should be medically stable before the surgery, if possible.

Description

Coronary artery bypass graft surgery builds a detour around one or more blocked coronary arteries with a graft from a healthy vein or artery. The graft goes around the clogged artery (or arteries) to create new pathways for oxygen-rich blood to flow to the heart.

Coronary artery bypass graft surgery is major surgery performed in a hospital. The length of the procedure depends upon the number of arteries being bypassed, but it generally takes from 4 to 6 hours--sometimes longer. The average hospital stay is 4 to 7 days. Full recovery from coronary artery bypass graft surgery takes 3 to 4 months. Within 4 to 6 weeks, people with sedentary office jobs can return to work; people with physical jobs must wait longer and sometimes change careers.

Coronary artery bypass graft surgery is widely performed in the United States. The American Heart Association estimates that 573,000 coronary artery bypass graft surgeries were performed on 363,000 patients in 1995. Seventy four percent of these procedures were performed on men and 44% on men and women under the age of 65 (1995 data). The estimated average cost of this procedure in 1995 was $44,820.

Procedure

The surgery team for coronary artery bypass graft surgery includes the cardiovascular surgeon, assisting surgeons, a cardiovascular anesthesiologist, a perfusion technologist (who operates the heart-lung machine), and specially trained nurses. After general anesthesia is administered, the surgeon removes the veins or prepares the arteries for grafting. If the saphenous vein is to be used, a series of incisions are made in the patient's thigh or calf. More commonly, a segment of the internal mammary artery will be used and the incisions are made in the chest wall. The surgeon then makes an incision from the patient's neck to navel, saws through the breastbone, and retracts the rib cage open to expose the heart. The patient is connected to a heart-lung machine, also called a cardiopulmonary bypass pump, which cools the body to reduce the need for oxygen and takes over for the heart and lungs during the procedure. The heart is then stopped and a cold solution of potassium-enriched normal saline is injected into the aortic root and the coronary arteries to lower the temperature of the heart, which prevents damage to the tissue.

Next, a small opening is made just below the blockage in the diseased coronary artery. Blood will be redirected through this opening once the graft is sewn in place. If a leg vein is used, one end is connected to the coronary artery and the other to the aorta. If a mammary artery is used, one end is connected to the coronary artery while the other remains attached to the aorta. The procedure is repeated on as many coronary arteries as necessary. Most patients who have coronary artery bypass graft surgery have at least three grafts done during the procedure.

Electric shocks start the heart pumping again after the grafts have been completed. The heart-lung machine is turned off and the blood slowly returns to normal body temperature. After implanting pacing electrodes (if needed) and inserting a chest tube, the surgeon closes the chest cavity.

Success rate of coronary artery bypass graft surgery

About 90% of patients experience significant improvements after coronary artery bypass graft surgery. Patients experience full relief from chest pain and resume their normal activities in about 70% of the cases; the remaining 20% experience partial relief. In 5-10% of coronary artery bypass graft surgeries, the bypass graft stops supplying blood to the bypassed artery within one year. Younger people who are healthy except for the heart disease do well with bypass surgery. Patients who have poorer results from coronary artery bypass graft surgery include those over the age of 70, and those who have poor left ventricular function, or are undergoing a repeat surgery or other procedures concurrently, as well as those who continue smoking, do not treat high cholesterol or other coronary risk factors, or have another debilitating disease.

Long term, symptoms recur in only about 3-4% of patients per year. Five years after coronary artery bypass graft surgery, survival expectancy is 90%, at 10 years it is about 80%, at 15 years it is about 55%, and at 20 years it is about 40%.

Angina recurs in about 40% of patients after about 10 years. In most cases, it is less severe than before the surgery and can be controlled by drug therapy. In patients who have had vein grafts, 40% of the grafts are severely obstructed 10 years after the procedure. Repeat coronary artery bypass graft surgery may be necessary, and is usually less successful than the first surgery.

Minimally invasive coronary artery bypass graft surgery

There are two new types of minimally invasive coronary artery bypass graft surgery: port-access coronary artery bypass (also called PACAB or PortCAB) and minimally invasive coronary artery bypass (also called MIDCAB). These procedures are minimally invasive because they do not require the neck-to-navel incision, sawing through the breastbone, or opening the rib cage to expose the heart. Both procedures enable surgeons to work on the coronary arteries through small chest holes called ports and other small incisions. Port-access coronary artery bypass requires the use of a heart-lung machine but minimally invasive coronary artery bypass does not. Advantages of these procedures over standard coronary artery bypass graft surgery include a shorter hospital stay, a shorter recovery period, and lower costs.

Port-access coronary artery bypass enables surgeons to perform bypasses through smaller incisions. Using a video monitor to view the procedure, the surgeon passes instruments through ports in the patient's chest to perform the bypass. Mammary arteries or leg veins are used for the grafts. Minimally invasive coronary artery bypass is performed on a beating heart and is appropriate only for bypasses of one or two arteries. Small ports are made in the patient's chest, along with a small incision directly over the coronary artery to be bypassed. Generally, the surgeon uses a mammary artery for the bypass.

Early data on outcomes for port-access coronary artery bypass and minimally invasive coronary artery bypass are favorable. Mortality rates with port-access coronary artery bypass and minimally invasive coronary artery bypass are both less than 3%--about the same as in standard coronary artery bypass graft surgery. One clinical trial indicated that survival at seven years was the same in minimally invasive coronary artery bypass and standard coronary artery bypass graft surgery, but that another intervention was necessary five times more often with minimally invasive coronary artery bypass than with standard coronary artery bypass graft surgery. The American Heart Association Council on Cardio-Thoracic and Vascular Surgery feels that both procedures appear promising but that further study is needed. More data covering longer term outcomes are necessary in order to fully assess these procedures.

Preparation

The patient is usually admitted to the hospital the day before the coronary artery bypass graft surgery is scheduled. Coronary angiography has been previously performed to show the surgeon where the arteries are blocked and where the grafts might best be positioned. The patient is given a blood-thinning drug--usually heparin--which helps to prevent blood clots. The evening before the surgery, the patient showers with antiseptic soap and is shaved from chin to toes. After midnight, food and fluids are restricted. A sedative is prescribed on the morning of surgery and sometimes the night before. Heart monitoring begins.

Aftercare

The patient recovers in a surgical intensive care unit for at least the first two days after the surgery. He or she is connected to chest and breathing tubes, a mechanical ventilator, a heart monitor and other monitoring equipment, and a urinary catheter. The breathing tube and ventilator are usually removed within six hours of surgery, but the other tubes remain in place as long as the patient is in the intensive care unit. Drugs are prescribed to control pain and to prevent unwanted blood clotting. The patient is closely monitored. Vital signs and other parameters, such as heart sounds and oxygen and carbon dioxide levels in arterial blood, are checked frequently. The chest tube is checked to ensure that it is draining properly. The patient is fed intravenously for the first day or two. Daily doses of aspirin are started within 6-24 hours after the procedure. Chest physiotherapy is started after the ventilator and breathing tube are removed. The therapy includes coughing, turning frequently, and taking deep breaths. Other exercises will be encouraged to improve the patient's circulation and prevent complications due to prolonged bed rest.

If there are no complications, the patient begins to resume a normal routine around the second day. This includes eating regular food, sitting up, and walking around a little bit. Before being released from the hospital, the patient usually spends a few days under observation in a non-surgical unit. During this time, counseling is usually provided on eating right and starting a light exercise program to keep the heart healthy. Patients should eat a lot of fruits, vegetables, grains, and non-fat or low-fat dairy products, and reduce fats to less than 30% of all calories. An exercise program will usually be tailored for the patient, who will be encouraged to participate in a cardiac rehabilitation program, where exercise will be supervised by professionals. Cardiac rehabilitation programs, offered by hospitals and other organizations, may also include classes on heart-healthy living.

Full recovery from coronary artery bypass graft surgery takes three to four months and is a gradual process. Upon release from the hospital, the patient will feel weak because of the extended bed rest in the hospital. Within a few weeks, the patient should begin to feel stronger.

While the incision scar from coronary artery bypass graft surgery heals, which takes one to two months, it may be sore. The scar should not be bumped, scratched, or otherwise disturbed. An exercise test is often conducted after the patient leaves the hospital to determine how effective the surgery was and to confirm that progressive exercise is safe.

Risks

Coronary artery bypass graft surgery is major surgery and patients may experience any of the complications associated with major surgery. The risk of death during coronary artery bypass graft surgery is two to three percent. Possible complications include graft closure and development of blockages in other arteries, long-term development of atherosclerotic disease of saphenous vein grafts, abnormal heart rhythms, high or low blood pressure, blood clots that can lead to a stroke or heart attack, infections, and depression. There is a higher risk for complications in patients who are heavy smokers, patients who have serious lung, kidney, or metabolic problems, or patients who have a reduced supply of blood to the brain.

Terms:
Aorta
The main artery which carries blood from the heart to the rest of the body The aorta is the largest artery in the body.
Graft
To implant living tissue surgically. In coronary artery bypass graft surgery, healthy veins or arteries are grafted to coronary arteries.
Mammary artery
A chest wall artery that descends from the aorta and is commonly used for bypass grafts.
Saphenous vein
A long vein in the thigh or calf commonly used for bypass grafts.
Ventricles
The left and right ventricles are the large chambers of the heart. The ventricles propel blood to the lungs and the rest of the body.


Resources:
BOOKS
American Heart Association. "Considering Surgery or Other Interventions." In Guide to Heart Attack Treatment, Recovery, Prevention. New York: Time Books, 1996.
DeBakey, Michael E. and Antonio M. Gotto, Jr. "Surgical Treatment of Coronary Artery Disease." In The New Living Heart. Holbrook, MA: Adams Media Corporation, 1997.
Texas Heart Institute. "Heart Surgery." In Texas Heart Institute Heart Owners Handbook. New York: John Wiley & Sons, 1996.
PERIODICALS
Bauman, Alisa. "Too Many Bypasses?" Men's Health 78(March 1998): 80-81.
Faxon, David P. "Myocardial Revascularization in 1997: Angioplasty Versus Bypass Surgery." American Family Physician (October 1, 1997): 1409-1417.
Hicks, Jr., George L. "Cardiac Surgery." Journal of the American College of Surgeons 186, no. 2(February 1998): 129-132.
Smith, Laquita Bowen. "Not-So-Open Heart Surgery: New Equipment Allows for a Three-Inch Incision." Memphis Business Journal 18, no. 53(May 12 1997): 49.
Solomon, Allen J. and Bernard J. Gersh. "Management of Chronic Stable Angina: Medical Therapy, Percutaneous Transluminal Coronary Angioplasty, and Coronary Artery Bypass Graft Surgery." Annals of Internal Medicine 128(February 1, 1998): 216-223.
ORGANIZATIONS
American Heart Association. National Center. 7272 Greenville Avenue, Dallas, TX 75231-4596. (214) 373-6300. http://www.medsearch.com/pf/profiles/amerh/.
Texas Heart Institute Heart Information Service. P.O. Box 20345, Houston, TX 77225-0345. 1-800-292-2221. Http://www.tmc.edu/thi/his.html.

--------------------------------------------------------------------------------



The above information is an educational aid only. It is not intended as medical advice for individual conditions or treatments. Talk to your doctor, nurse or pharmacist before following any medical regimen to see if it is safe and effective for you.

This health encyclopedia is made possible by the Dr. Joseph F. Smith Trust Fund. Dr. Smith was a surgeon who resided in Wausau from 1908 to 1952. In addition to his surgical practice, Dr. Smith possessed a strong commitment to community service and medical education. The agreement which created the Dr. Joseph F. Smith Medical library was signed in July of 1948.

Copyright 1999-2003. The Thomson Corporation. All rights reserved. MyDiseaseDex(TM) is a trademark of Micromedex, Inc.


Medical Library, 333 Pine Ridge Blvd. Wausau, WI 54401, Phone: 715-847-2184, Fax, 715-847-2183
http://www.chclibrary.org/

Six Behaviors that Increase Self-Esteem

Six Behaviors that Increase Self-Esteem by Denis Waitley

Following are six behaviors that increase self-esteem, enhance your self-confidence, and spur your motivation. You may recognize some of them as things you naturally do in your interactions with other people. But if you don't, I suggest you motivate yourself to take some of these important steps immediately.

First, greet others with a smile and look them directly in the eye. A smile and direct eye contact convey confidence born of self-respect. In the same way, answer the phone pleasantly in the office and at home, and when placing a call, give your name before asking to speak to the party you want to reach. Leading with your name underscores that a person with self-respect is making the call.

Second, always show real appreciation for a gift or complement. Don't downplay or sidestep expressions of affection or honor from others. The ability to accept or receive is a universal mark of an individual with solid self-esteem.

Third, don't brag. It's almost a paradox that genuine modesty is actually part of the capacity to gracefully receive compliments. People who brag about their own exploits or demand special attention are simply trying to build themselves up in the eyes of others - and that's because they don't perceive themselves as already worthy of respect.

Fourth, don't make your problems the centerpiece of your conversation. Talk positively about your life and the progress you're trying to make. Be aware of any negative thinking, and take notice of how often you complain. When you hear yourself criticize someone - and this includes self-criticism - find a way to be helpful instead of critical.

Fifth, respond to difficult times or depressing moments by increasing your level of productive activity. When your self-esteem is being challenged, don't sit around and fall victim to "paralysis by analysis." The late Malcolm Forbes said, "Vehicles in motion use their generators to charge their own batteries. Unless you happen to be a golf cart, you can't recharge your battery when you're parked in the garage!"

Sixth, choose to see mistakes and rejections as opportunities to learn. View a failure as the conclusion of one performance, not the end of your entire career. Own up to your shortcomings, but refuse to see yourself as a failure. A failure may be something you have done - and it may even be something you'll have to do again on the way to success - but a failure is definitely not something you are.

Even if you're at a point where you're feeling very negatively about yourself, be aware that you're now ideally positioned to make rapid and dramatic improvement. A negative self-evaluation, if it's honest and insightful, takes much more courage and character than the self-delusions that underlie arrogance and conceit. I've seen the truth of this proven many times in my work with athletes. After an extremely poor performance, a team or an individual athlete often does much better the next time out, especially when the poor performance was so bad that there was simply no way to shirk responsibility for it. Disappointment, defeat, and even apparent failure are in no way permanent conditions unless we choose to make them so. On the contrary, these undeniably painful experiences can be the solid foundation on which to build future success.

Leading a World Class Life

Leading a World Class Life By Jim Rohn

Every four years the world is given the gift of the Olympics. For a few weeks nations lay down their arms and come together to let their world class athletes compete on a level playing field to see who the best is in the many events. Such amazing athleticism was on display the past few weeks. It boggles the mind what these young men and women can accomplish with their bodies. Great feats of skill and determination bring them to the pinnacle of athletic achievement. Incredible.

As I think about what it takes to become a world class athlete capable of competing at the Olympic level, I realize that there are some foundational lessons for all of us to learn as it relates to becoming world class in whatever we set our hands to.

The secret of how these athletes became world class is found in the combination of two fundamental ideas: Desire and dedication.

A 22 year old man doesn't simply wake up one day and find that he is on the Olympic basketball team. No, it started years before. In fact, it probably started when he was only six or seven years old. Maybe his father took him to a basketball game and that little boy said, "Someday daddy, I am going to be a basketball player." That was the first sign of desire. Desire is key. World class people start with desire. They have to at some point "want it".

But we all know people who dream of big things but never accomplish those dreams, don't we? Why is that? After all, they have desire. They want it. But the engine that drives the dream is dedication. Desire tells you what you want, while dedication is what will get it for you.

Someone may see a young gymnast and say, "Wow, that looks easy." What they don't see or perhaps overlook is the years of practice. The years of getting up at 4:30 every morning and going to the gym before going to school. It is the
dedication of the young athlete, the many times of failing in practice, the many times of falling off the equipment and faithfully getting back on that turns a wisher into a world class doer.

A person with desire but no dedication will never achieve much. You must have the powerful combination of both.

So let's take a closer look at each of these and gain some insight into what desire and dedication are all about.

Desire. There are three parts to desire:

.. Dreaming
.. The Vision
.. Focus

First, is dreaming. Have you let yourself dream lately? Just sit down and begin to imagine all oftheincrediblepossibilitiesyourlifecouldbecomeSpendsometimejustdreaming.

Next is the vision. Once you dream, you begin to cut back on all of thepossibilitiesandnarrowittowhatpossibilityitisthatyoureallywant.Youbegintocreateavisionforyourlife.Youbegintoseeitasyouwantit.

Lastly under desire is focus. Once you have the vision, you have to really focus in on that dream. This is where you get really specific about what your life is going to look like.

Now for dedication. There are also three parts:

.. The Plan
.. Beginning
.. Perseverance

First is the plan. Without a plan you will drift to and fro. You will certainly not carry out your dream if you do not have a plan. So write it down. Set your goals. Know what you want and how you are going to get there.

Second is the beginning. This may sound simple and yet it is simply profound. Manypeoplehaveadreamandtheyevenhaveaplan,buttheyneverbegin.SosimpleJuststart.Thefirststeponthelongjourneyisstilljustonestep.Ifyouhaveadreamandaplan,takeastepintherightdirection.

Lastly is to persevere. Every road to every dream has a section or sections that is hard to travel. Every great dream will encounter difficulty. The question isn't whether or not you will encounter trouble, but how you will respond to trouble. Will you quit when the going gets tough or will you persevere? I have found that every successful person I know, myself included, has encountered problems along the way that tempted them to quit. Yet they persevered and achieved their dream.

Let's take a look at the progression. As you do, think about where you are in the progression of becoming a world class dream pursuer.

1. Dream
2. Create a vision
3. Focus the vision
4. Develop a plan
5. Begin to pursue the dream
6. Persevere

Friends, I hope for you the fulfillment of every dream that you have. That is what life is about isn't it? But to do so, I know that you will have to combine your desire with good old dedication. And when you combine those two, you will be well on your way to leading a world class life!

social support

Build your social support network - By Linda Dessau, the
Self-Care Coach **
----------------------------------------------------

A social support network is a group of people who you can count on to
support you. They may be the first people you call when something
upsetting has happened, when you have a difficult decision to make, or
when you have fantastic news to share. Some of the people in your social
support network might be professionals and support you in very specific
ways (i.e. your family doctor or your life coach), and other people in
your network you might live with or be in contact with every day.

First, let's talk about why social support is important and why it matters
to your self-care. Research has shown that a lack of social support
(isolation) can contribute to an ongoing state of chronic stress, which
will negatively impact your immune system and put you at risk for
dangerous conditions.

Now, what can strengthening your social support network do for you? Social
support can improve the functioning of your immune system, protecting you
from disease, and it can increase your vitality, decrease your stress and
improve your self-esteem.

WHAT MAKES A SOCIAL SUPPORT NETWORK SOLID?

STRENGTH – Make sure that you're not counting on one or two people to
provide all the support you need. That can be hard on them, and on you (if
they're suddenly unable to be there for you). Reach out regularly to
several people.

VARIETY – Similarly, having many people in your support network gives you
access to their different skills, perspectives and experiences.

COMMON GROUND - If you're dealing with a particularly difficult challenge
or have a very specific goal, then finding and regularly interacting with
others in the "same boat" can have extremely beneficial results. Whether
it's finding out how others have handled a situation, or sharing some of
your experience, groups like this can be a great boost to your self-care
program.

SOMETHING TO REACH FOR – Make a point of building or strengthening your
relationships with people who inspire, encourage and support you, and who
empower you to grow and to be your best self. For instance, someone who is
very committed to his or her own self-care will inspire you to make
positive self-care choices. And someone who is very loving and supportive
will help you to feel good about yourself.

5 WAYS TO NURTURE YOUR SUPPORT NETWORK

1. Call or write when things are good as well as when they're not. Sharing
your gratitude and appreciation can help to deepen your relationships and
will also intensify your good feelings.

2. Be open to new people. You never know when someone new is going to come
into your life or the unique gifts they will bring. I believe that
sometimes we're meant to connect with certain people only briefly – so
instead of thinking, "I don't have time for a new friend,", go with your
heart and get curious about what you can learn from interacting with this
person.

3. Offer to help. Whether it's people you know or people you haven't met
yet (i.e. through a volunteer position), helping others can be a wonderful
boost for your own self-care. AND remember that YOUR self-care still comes
first!

4. Live by the Four Agreements, as created by Don Miguel Ruiz - Be
impeccable with your word, don't take anything personally, don't make
assumptions and always do your best. For more information about the Four
Agreements, visit http://www.miguelruiz.com/agreements.html.

5. If you don't feel like talking to anyone, talk to someone. Sometimes we
choose to be isolated. It can be really difficult to reach out when we
feel like this. Do it anyway.

It's important to remember that your social relationships can also have a
negative impact on your self-care. Unspoken truths, unintentional
sabotage, or continuously taking on the role of care-giver can all add
stress and affect your commitment to self-care.

So instead, nourish your positive relationships and keep your social
support network strong and working for you.
About the Submitter