Disclaimer: This information is provided with the understanding that it is supplemental educational material and not medical advice or recommendation.The reader should not rely on this information to replace consultations with qualified health care professionals to meet your individual medical needs.
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When coronary artery disease is treated there are usually four major alternatives that are not always exclusive. The first is modifying risk factors. This includes changing dietary habits, discontinuation of smoking, limitation of sedentary lifestyle, and tight blood sugar control for diabetics. The second approach is medical intervention with beta-blockers, lipid lowering agents, and antihypertensives. The next step is cardiac catheterization. Through injection of dye directly into the coronary arteries and special xray equipment high quality pictures of the vessels supplying blood to the heart may be visualized. Then the blockages may be opened with balloon dilatation and kept open with stents. The risks of this procedure include stroke, restenosis (blockage of the vessels again), and possible death. If these options fail or are not able to be applied then surgery may be required.
Surgery is traditionally done through an incision in the front part of the chest and then the breast bone is divided and later repaired with wire. Conduits or materials for the actual bypasses are then harvested. These may include arteries from inside the chest (internal thoracic or mammary arteries), arteries from the arms (radial arteries), or veins from the legs. These are then used to carry the blood around the blockage to the heart muscle that needs more blood and oxygen. This may be done with or without the use of the heart-lung machine.
CABG is very common and safe. It has stood the test of time. This procedure has been studied for decades. It remains the longest lasting intervention that can be completed for coronary artery disease. There are complications, however, that may occur. These include, but are not limited to, atrial fibrillation (irregular heart beat), infection, myocardial infarction (heart attack), stroke, bleeding, and possible death.
Note: It is standard of care in coronary bypass surgery to use at least one internal mammary artery. Newer data suggests that using both internal mammary arteries is beneficial. Upstate surgeons are very aggressive in using both internal mammary arteries to achieve the most benefit for the patient.
The aortic valve is a heart valve which allows blood to flow out of the heart to the rest of the body, but does notpermit it to go backwards. Aortic stenosis refers to the condition where the orifice or opening of the aortic valve is narrowed. This may occur due to many reasons including rheumatic disease, congenital bicuspid valve, or calcium deposits. The normal orifice area of the valve is at least 2.53.5 square centimeters. When this narrows to less than 1 square centimeter patients may become symptomatic. Once the valve is significantly diseased usually medicines or catheter based interventions do not help. The majority of the time repair is also not an option. This leaves valve replacement. Although there are currently many choices to replace the aortic valve, the most common two options include a mechanical valve or a tissue valve (please refer to the section entitled Types of valves for replacement). Unlike the CABG procedure aortic valve surgery requires the use of the heart-lung machine because the surgeon is working inside the heart. The possible complications are similar to CABG plus the new valve may leak and the chances of having a stroke are slightly higher.
Aortic insufficiency refers to the aortic valve leaking and allowing blood to flow backwards from the aorta into the heart after it has been ejected from the heart. There are many causes of this problem. They include rheumatic disease, endocarditis (infection of the valve), connective tissue diseases (weakening of the tissues that make up the support structures within the body), and congenital diseases. Although the aortic valve may occaisionally be repaired more often it requires replacement. The options for replacement may be viewed in the section Types of valves for replacement and the complications are similar to those of aortic valve replacement in aortic stenosis.
There are several categories of valves that may be utilized for cardiac valve replacement. These include mechanical, tissue, cadaveric, and the transplantation of the patients healthy pulmonary valve to replace the diseased valve. The most common types of valves are tissue valves and mechanical valves. Tissue valves are based on animal hearts and surrounding structures. The advantage of tissue valvesis that warfarin (coumadin) is not required long term after their placement. The disadvantage is that they eventually wear out. This time period varies from patient to patient and they tend to last longer in the aortic position than the mitral position. Mechanical valves on the other hand rarely need to be replaced due to detioration. They do require the use of coumadin daily for the entire time they are in place.
The mitral valve prevents blood from going backwards to the left atrium and lungs after it has entered the left ventricle. Mitral stenosis refers to narrowing of the mitral valve orifice or opening. The valve orifice is usually about 46 square centimeters. Once it gets below 2 square centimeters problems may occur. Sometimes this can be treated with catheter interventions or surgically repairing the diseased valve but often it requires surgical replacement of the valve. Again there are different options for replacing the mitral valve (please refer to the section Types of valves for replacement). The complications are similar to CABG plus the new valve may leak and the chances of having a stroke are slightly higher.
The mitral valve prevents blood from going backwards to the left atrium and lungs after it has entered the left ventricle. Mitral insufficiency is the term applied to the condition where blood is allowed to flow backwards from the left ventricle to the left atrium through the mitral valve. If the blood does go backwards instead of exiting the heart via the aortic valve it will wind up in the left atrium and may cause problems with the blood flow through the lungs. This condition may arise due to valve degeneration, ischemic disease (coronary artery blockage), or rheumatic fever. Many times this is mild and does not need intervention or symptoms may be helped with medications. If the regurgitation is bad enough surgery may be required. When surgery is required, the valve may be repaired sometimes or replaced depending on why it is leaking. For additional infromation on valve repair please see the section Mitral Valve Repair. Again there are different options for replacing the mitral valve (please refer to the section Types of valves for replacement). The complications are similar to those of mitral valve replacement in mitral stenosis.
There are several categories of valves that may be utilized for cardiac valve replacement. These include mechanical, tissue, and cadiveric valves to replace the diseased valve. The most common types of valves are tissue valves and mechanical valves. Tissue valves are based on animal hearts and surrounding structures. The advantage of tissue valves are that warfarin (coumadin) is not required long term after there placement. The disadvantage is that they eventually wear out. This time period varies from patient to patient and they tend to last longer in the aortic position than the mitral position. Mechanical valves on the other hand rarely need to be replaced due to detioration. They do require the use of coumadin daily for the entire time they are in place.
Mitral valve repair is a surgical technique which requires the use of the heart lung machine to fix the mitral valve instead of replacing the valve. This usually entails placing a ring around the valve which helps firmly support the leaflets and reshape the valve and the structures below the valve (refer to picture above). Warfarin (coumadin) which is a blood thinner is usually not required long term after this operation unless the patient has atrial fibrillation (irregular heart beat) or another disease which requires its usage.
Atrial fibrillation is a heart condition that is characterized by an irregular heart beat. It places the patient at an increased risk for having a stroke. This is often treated with coumadin to thin the blood and prevent clots from forming inside the heart. Other types of medication can also be used. When the patient has a structual heart problem causing atrial fibrillation, surgery for atrial fibrillation can be completed. This is called a Maze or modified Maze procedure. It is successful about 7080% of the time.
The aorta is the major arterial blood vessel in the body. It supplies oxygenated blood to the body. An aortic aneurysm is a dilatation of the aorta. As the aorta dilates it is prone to rupture or leak. When the diameter gets large enough the risk of surgery is lower than the risk of it leaking. Surgery involves replacing the dilated segment with prosthetic material. This can be done relatively safely but the risks include, but are not limited to infection, myocardial infarction (heart attack), stroke, paraplegia (depending on the section of aortareplaced), and death.
Most patients undergoing heart surgery are admitted to the hospital the same day as the surgery. This requires that blood work, xray, and anesthesia evaluationtake place prior to admission. This is usually is done one morning or afternoon scheduled at the patients convenience. The morning of the surgery after the patient checks in, he is given medication to help relax. The anesthiologist then places special monitoring lines in arteries and veins. After this is completed the patient is taken to the operating room and goes to sleep. The surgery then takes place and afterwards the patient is taken to the intensive care unit. At this point in time the patient is usually still asleep and on the ventilator (breathing machine). After the patient awakens the ventilator is discontinued. The patient is transfered out of the intensive care unit when most of the intravenous medications are stopped. The length of stay depends on the procedure completed, the health of the patient prior to surgery, and the support at home. Some people require inpatient rehabilitation. Temporary restrictions include no driving automobiles for three weeks and no heavy lifting for six weeks but all is dependent on the procedure and individual patient.