Coronary artery bypass grafting - indications, technique and duration, rehabilitation and complications

Indications and contraindications for

At the heart of ischemic heart disease is usually atherosclerosis of the coronary arteries. Cholesterol accumulates on their walls, plaques are formed, disrupting the permeability of blood vessels. The heart receives an insufficient amount of oxygen with the blood flow, and the person feels chest pains like angina pectoris. Popularly, this condition is known as angina pectoris. It is manifested by pressing, squeezing, burning cardialgias of a paroxysmal nature, at first associated with physical exertion or strong excitement, and later arising at rest.

Indication for coronary artery bypass grafting of stenotic vessels of the heart - the need to restore blood flow in the myocardium in such diseases:

• progressive, post-infarction and exertional angina;
• myocardial infarction.

Such conditions require performing coronary ventriculography (CVG) before choosing a tactic of action.

Coronary artery bypass grafting (CABG) is the method of choice if CVG reveals:

• hemodynamically significant stenosis of the coronary vessel of the heart (narrowing by more than 75%), including the trunk of the left coronary artery;
• simultaneous defeat of several branches of the channel;
• defect in the proximal parts of the right interventricular branch;
• the retained diameter of the artery is less than 1.5 mm.

Since cardiac bypass surgery requires good recovery capabilities from the body, it has a number of contraindications. These include severe somatic diseases:

• liver (cirrhosis, chronic hepatitis, dystrophic changes) with severe hepatocellular failure;
• kidney (renal failure of the last stages);
• lungs (emphysema, severe pneumonia, atelectasis).

As well as:

• decompensated diabetes mellitus;
• uncontrolled arterial hypertension.

The age of patients in itself is not a contraindication to heart bypass surgery when there are no severe concomitant diseases.

The doctor considers the listed indications and contraindications in a comprehensive manner, determining the degree of operational risk and deciding how to proceed further.

Bypass surgery after myocardial infarction

This operation for coronary syndrome is one of the options for radical treatment of the patient. It is carried out in cases when the state of the coronary vessel does not allow the placement of a stent or in case of retrombosis of the installed device (in such a situation, the artery is removed from the patient together with a spring and a shunt is implanted in its place). In other cases, the advantage of choice is always with a minimally invasive technique (stenting, ballooning, etc.).

Techniques and technique of execution

Bypass grafting is an abdominal operation that involves the formation of an additional pathway of blood flow to the heart, bypassing the affected segments of the coronary arteries. They operate both in a planned and an emergency manner. There are two methods of creating anastomoses in cardiac surgery: mammary-coronary artery (MCB) and coronary artery (CABG). In the coronary artery tract, a large saphenous vein of the thigh or veins of the leg is used as a substitute for replacement, and in the case of MCB, the internal thoracic artery.

Sequencing

1. The heart is accessed (usually through an incision in the sternum).
2. Simultaneous collection of transplants with sternotomy (removal of a vessel from another part of the body).
3. Cannulation of the ascending part of the aorta and vena cava, connecting the heart-lung machine AIK (it is pumped through a special device - a membrane oxygenator, which saturates the venous blood with oxygen, while allowing the aorta to be bypassed).
4. Cardioplegia (cardiac arrest by cooling).
5. Imposition of shunts (suturing of blood vessels).
6. Prevention of air embolism.
7. Restoration of cardiac activity.
8. Suturing the incision and draining the pericardial cavity.

Then the functioning of the anastomosis is checked using special techniques. Sometimes minimally invasive surgery is performed without connecting the AIK. It is performed on a beating heart, it threatens with a lower risk of complications and a shorter recovery time. However, this type of intervention requires extremely high qualifications of the surgeon.

For more information on the technique of performing CABG, see the video in the block below.

Early postoperative period

After the operation, the patient lies in the intensive care unit for several days. During this period, vital signs are monitored, the seams are treated with antiseptic solutions, and the drains are washed. Every day, a blood test is performed, a cardiogram is recorded, and body temperature is measured. Mild fever and cough are natural at first. After turning off the ventilator, the patient is trained in breathing exercises to effectively remove fluid from the lungs and prevent congestive pneumonia. For the same purpose, the patient is often turned to the sides and radiography of the OGK is performed several times. The patient receives the necessary medications.

If the condition is stable, and the patient's life is not in danger, he is transferred to the general ward in order to be further monitored and restored after cardiac bypass surgery. They gradually expand the motor regime, starting with walking near the bed, along the corridor. Areas of postoperative wounds are treated. The patient wears elastic stockings to reduce the swelling of the lower leg. Before discharge, the stitches are removed from the chest. The length of stay in the hospital varies within a week or more.

Rehabilitation

Recovery after surgery is a set of measures aimed at returning to everyday life, adequate physical activity and professional activity.

The entire period is divided into several stages:

1. Stationary period aimed at expanding the motor regime. The patient is allowed to sit down, then stand, walk around the room, etc., every day increasing the load on the heart under the strict supervision of the staff.
2. Long-term observation. After being discharged from the cardiology center, the patient continues to recover from bypass surgery at home. The patient, as a rule, is on sick leave to avoid overload and colds. You can return to work no earlier than six weeks after discharge (the term is set individually). It is usually extended to the driver or builder for up to three months. The patient should visit the local doctor and cardiologist 3, 6 and 12 months after the intervention. During each visit, an ECG is performed, the biochemical spectrum of lipids, a complete blood count, and, if necessary, a chest x-ray are determined. The main principle of the rehabilitation process at this stage is lifestyle modification. The concept implies good sleep (at least 7 hours), frequent fractional meals with the obligatory inclusion of polyunsaturated fatty acids in the diet, quitting smoking and alcohol abuse, sufficient physical activity, maintaining normal body weight (waist circumference in women <80 cm, in men < 94 cm). Despite a significant improvement in well-being and the disappearance of chest pain, the patient needs to adhere to the constant intake of certain medications. These include blood thinners, cholesterol lowering drugs, and antihypertensive drugs.
3. Sanatorium and health resort. Patients are advised to undergo a health improvement course in a specialized institution. A comprehensive program usually includes cardio training, exercise therapy and physical therapy.

The resumption of vascular patency by the CABG method, as a rule, significantly improves the quality of life of patients: angina attacks disappear, the likelihood of a heart attack after shunting decreases, and the ability to work is restored. The need for medication is reduced to a preventive minimum. However, it is worth noting that there is a risk of recurrent thrombosis, and only if the recommendations regarding the lifestyle are followed will it be possible to maintain health for a long time.

How long do you live after surgery?

The duration of life after the intervention is a rather individual parameter, which depends on the volume of the affected myocardium and the duration of the stay of the heart muscle in conditions of ischemia. An important role is played by the presence of concomitant diseases such as diabetes mellitus and hypertension. On average, patients after CABG live from 5 to 25 years, but statistics in this matter are not a key factor, an important point is the specific state of the human body in question.

Complications

Complications after bypass surgery can occur during surgery and after discharge. As mentioned above, the risk of adverse consequences is assessed before the intervention, it depends on the background state of the organism. The most common problems include:

• acute renal failure;
• thrombosis;
• cardiac arrest;
• rhythm disturbances;
• myocardial infarction;
• infection, including sepsis;
• pneumonia;
• bleeding;
• pericarditis and cardiac tamponade;
• pulmonary edema;
• cardiogenic shock;
• neurosis.

A long-term complication is shunt stenosis due to non-compliance with the doctor's recommendations. In this case, the patency of the vessels again becomes difficult, a typical clinical picture of angina pectoris arises. This situation requires repeated coronary artery bypass grafting.

Feedback from patients after bypass surgery

There are a large number of methods for restoring blood circulation in the heart muscle: stenting, ballooning, and others. Bypass surgery is the most radical possible technique, allowing oxygen supply to be restored by replacing the vessel. Patients who undergo such an intervention always feel an improvement in their condition. It is associated with the complete disappearance of symptoms, an increase in exercise tolerance and quality of life. We never recommend refusing to carry out this procedure in cases where there are reasoned indications for it, because only in this way the patient has a chance of recovery.

Cost in Russia and other countries

The price of the procedure is quite high: in foreign clinics, the operation can cost from 8 to 40 thousand dollars, in domestic cardiological centers - from 100 to 300 thousand rubles. Citizens of the Russian Federation can always inquire about quotas and benefits for undergoing treatment from their specialized cardiologist.

Conclusions

The operation of coronary artery bypass grafting of the heart vessels has gained popularity in modern cardiac surgery. The method provides adequate myocardial perfusion, thereby improving the quality of life, preventing early disability and significantly reducing mortality from cardiovascular pathology.