Coronary artery bypass grafting (CABG)

What is coronary artery bypass grafting (CABG)?

Coronary artery bypass grafting (CABG) is a surgical procedure performed on patients with severe coronary artery disease (CAD). 

The condition is characterized by a partially blocked artery.

Such blockage could be a result of the accumulation of fatty material (plaque) in the arterial walls. 

Coronary arteries transport oxygen-rich blood into the heart.

A severely blocked coronary artery can lead to such symptoms as shortness of breath and angina. 

CAD has been identified as one of the leading causes of the majority of heart attacks.

The goal of CABG is to create a new pathway that will increase the supply of nutrients and oxygen-rich blood to the heart muscle. 

The procedure involves the use of grafts or blood vessels from your chest or leg to act as a bypass for the blocked artery, promoting blood flow. 

During surgery, your surgeon attaches the graft to an area of the artery slightly above the blockage (aorta). The other end of the graft gets attached beneath the blockage. 

The graft avoids the blockage and promotes the flow of oxygen-rich blood into the heart muscle. The surgeon may elect to bypass more than one coronary artery depending on the severity of the blockage. 

What are the considerations for CABG?

People with the following conditions are likely to benefit the most from CABG:

• Individuals with CAD who have suffered an MI, for whom percutaneous coronary intervention may not work

• Individuals with chest pain occasioned by CAN and which is resistant to medication

• People diagnosed with heart failure

• Individuals with several blocked or narrowed coronary artery

• Persons with diabetes-induced CAD

• Persons with severe abnormal heart rhythm (arrhythmia) 

Signs and symptoms 

People with CAD that may necessitate a CABG usually present with the following signs and symptoms:

• Odema (swollen feet and hands)

• Chest pain

• Arrhythmia (abnormal heart rhythm)

• Angina (chest tightness)

• Dyspnea (shortness of breath)

• Poor digestion

What are the different types of CABG? 

The techniques for CABG tend to vary, depending on the individual needs of a patient. There are several types of CABG in use today: 

Open-heart CABG 

The surgeon makes a long incision on your chest.

He/she separates the breakbone to gain access to your heart. 

In conventional CABG, the surgeon administers drugs to the patient with the goal of stopping the heartbeat.

The surgeon connects your heart to a heart-lung bypass device. 

The heart-lung machines ensure a constant circulation of oxygen-rich blood across your body over the duration of the procedure. 

The surgeon takes a vein or artery from your chest, leg, or arm to act as a graft.

The surgeon sews one end of the graft to the aorta while the other end gets connected with the blocked coronary artery. 

In case there has been blockage or narrowing to several coronary arteries, the surgical team utilizes the same technique to perform a bypass. 

Following the completion of this procedure, the surgeon restarts your heart and removes it from the heart-lung bypass device. 

The surgeon uses surgical wires to stick stock together the breastbone and close the chest. 

Minimally invasive CABG 

This is an effective and safe form of CABG where the surgeon makes a small incision of your rib cage and sternum, as opposed to a large incision. 

Unlike conventional surgery, minimally invasive CABG is less painful while the recovery time is faster. 

The risk of post-surgery complications is lesser.

Minimally invasive CABG has minimal blood loss further minimizing the risk for blood-borne infection. 

Robot-assisted CABG 

In this procedure, your surgeon performs CABG surgery using robot-controlled surgical tools.

It is also a minimally invasive procedure implying only a small part of your sternum gets opened, meaning faster recovery. 

Off-pump CABG 

The surgeon obtains a vein or artery from another part of your body for use as a “bypass” to the part of the blocked vessel. 

The graft restores blood flow.

Off-pump CABG is beneficial to patients with kidney problems. 

Patients with severe atherosclerosis and those suffering from chronic lung disease will also benefit from a CABG procedure. 

Off-pump CABG corrects irregular heart rhythm and reduces the risk of postoperative infection and/or inflammation. 

Hybrid procedure

A hybrid CABG procedure overcomes the problems of a blocked coronary artery by bypassing some blockages. 

It is a minimally invasive procedure often performed by a highly specialized surgical team with extensive training in stenting and CABG.

Preparing for a CABG procedure

A CABG procedure can be conducted as a matter of an emergency.

An emergency CABG surgery occurs if the patient has severe heart failure or has suffered a heart attack.

Other times, the procedure is scheduled ahead of time.

For a scheduled surgery, it is important that you speak to your surgeon beforehand and establish what to expect during surgery. 

You will also have time to ask any questions that you might have about the surgery and how best to prepare.

Your doctor will likely order a battery of tests to establish the seriousness and severity of your CAD. 

Some of the tests that your surgeon might order include: 

Electrocardiogram – The objective of the electrocardiogram test is to display your heart’s electrical activity. That way, your doctors can tell whether the heart is working properly, or not. 

Chest X-ray -The chest X-ray test provides a lungs and heart image that encompasses blood vessels. It will assist the surgical team in identifying points of blockage. 

Cardiac catheterization – During this test, the doctor inserts a thin and long tube (catheter) into a vein or artery in your arm or neck. 

The catheter is then threaded to your heart.

The doctors inject a solution through the catheter into the artery. This solution acts as a contrast and assists with taking of X-ray image of the artery. 

These heart imaging tests will also help to pinpoint the point where your coronary arteries have narrowed. 

Echocardiogram – This procedure relies on sound waves to evaluate the structure and function of your heart valves and muscles. 

Your physician is interested in determining whether the valves are leaking or are stiffened.

In case your physician establishes an abnormal flow of blood in the carotid arteries, he will likely order a CT angiogram. 

This test is also necessary for patients who have suffered a transient ischemic attack (TIA) or those with severe heart disease. 

For patients with chronic obstructive pulmonary disease (COPD) or emphysema, the physician can order a pulmonary function test. This helps to establish if your lungs have the capacity to withstand surgery. 

The test also aids in establishing if some of the symptoms are due to heart disease or lung disease.

It is important to explore the different treatment options available for the procedure. 

Ask your physician about the possible complications or risks that come with this surgery.

Effectiveness of CABG 

While CABG is not a cure for CAD or atherosclerosis that may occasion a blockage, it has been shown to minimize the risk of death from heart disease. 

CABG also reduces the severity of symptoms including shortness of breath and chest pain.

The surgery is also associated with significant improvements in the quality of life and cardiovascular health of the patient, including better sleep quality. 

CABG also reduced the patient’s mortality rate along with the risk of Myocardial infarction (MI).

Duration of surgery

Typically, a CABG procedure takes between 3 and 6 hours.

The surgery could be longer based on the number of blocked arteries or blood vessels identified by your surgeon for attachment. 

If the procedure is less invasive, such as in the case of Robot-assisted CABS or minimally invasive CABG.

Alternatives to CABG surgery

If you have blocked arteries due to CAD or atherosclerosis, your surgeon may propose other alternative procedures to CABG. These include: 

Coronary angioplasty

Your surgeon inserts a catheter into your arm or groin where the blockage has occurred.

This is a flexible plastic tube with a balloon attached at the end. 

The surgeon inflates this balloon, effectively widening the artery.

Unlike in CABG, coronary angioplasty is less invasive. 

The risk of complications in coronary angioplasty is also limited.

You are, however, likely to require further treatment due to a recurrence in a narrowed artery. 

Medication 

Beta-blockers are effective in relieving stable angina.

You can also reduce plaque buildup by taking cholesterol-reducing medication. 

Aspirin therapy, taken daily in low doses, is effective in patients with a past history of CAD or atherosclerosis.

Aspirin also prevents heart attacks. 

Enhanced External Counterpulsation (EECP) 

Your surgeon can also recommend EECP in place of CABS.

The procedure entails increasing blood flow by compressing blood vessels in the lower limbs. 

EECP improves blood flow to the heart muscles.

The goal of EECP is to initiate “extra” branches of blood vessels. The extra blood vessels become a “natural bypass.” 

EECP is an outpatient procedure often for a few hours each day, for the duration of seven weeks.

Is CABG reversible? 

CABG is an irreversible procedure.

Most patients can go for almost 15 years before it becomes necessary to insert another stent.

Benefits of CABG 

CABG has gained popularity as a surgical procedure of choice for treating heart problems.

Some of the benefits associated with his procedure include:

• A long history of application: CABG has been widely and successfully used by surgeons in both developed and developing countries as an effective treatment for heart diseases for nearly six decades.  
• Advancements in medical research have made CABG a reliable and vital technique in treating heart disease.  
• More effective when treating multiple blockages: In case a patient has several blocked arteries, CABG should be the surgical procedure of choice.  
• Due to better survival odds and enhanced long-term results, as documented by various studies.
• CABG is even more effective when integrated with advanced bypass techniques.  
• Reduced need or follow-up: Unlike an angioplasty procedure where the surgeon needs to follow the patient closely after surgery, in CABG, such a risk is reduced significantly.  

Risks or complications associated with CABG 

It is rare to develop serious complications after undergoing CABG.

There are, however, several risks that might accompany the procedure:

• Bleeding: This remains a major risk for all major procedures.
• Patients taking blood thinners are at a higher risk of bleeding.
• To minimize bleeding, your surgeon with guide and monitor you to stop taking this medication before surgery.
• Arrhythmias: Atrial fibrillation can be a concern for CABG.
• Irregular heartbeats put you at risk of a stroke.
• The good news is that this is not just a short-term concern.
• Infections: It is important to minimize infections during surgery.
• Infections can lead to sepsis that spreads across your body.
• CABG procedures incorporate improved surgical techniques and care. This minimizes the risk of infection.
• Delirium: Confusion may trigger unusual behavior in a patient, including memory problems.
• The patient may also get agitated.
• Graft failure: A CABG procedure aims for graft patency in the long term.
• Graft failure after CABG is a rarity but can be a health concern when it happens.
• The causes of graft failure remain unclear, but a narrowed graft can considerably impair blood flow to the heart muscle.
• Hypercoagulation and conduit size mismatch can also lead to graft failure.
• Other risk factors for CABG include:
• Heart attack
• Kidney failure
• Stroke
• Clots

The risk for CABS is dependent on several factors:

• Age – Elderly patients (that is, those older than 70 ) are at a high risk of developing complications following CABG on account of their advanced age.
• Smoking – Patients with coronary artery CAD or atherosclerosis are at a higher risk of bleeding after CABG.
• Diabetes – Diabetic patients are at risk of complications associated with a CABG procedure.
• Examples of complications include delays in wound healing, infection, and electrolyte imbalance.
• Chronic kidney disease: Patients with CKD are prone to adverse outcomes of a cardiovascular surgical procure.

Recovering after CABG 

Most patients take a few months to recover fully from surgery.

A patient may spend the first week after the procedure in the hospital.

During the first few days, the surgical team closely monitors the patient while recuperating in the intensive care unit (ICU).

After a few days, most patients get transferred to the general ward where their journey to recovery continues.

Upon discharge from the hospital, your healthcare provider will advise you on the kind of physical activities to avoid as these may strain the incision and your heart.

You are encouraged to gradually incorporate regular activities, including walking, as part of your recovery.

You will also be advised on the kind of medication to take to minimize the risk of post-surgical complications.

Your surgeon may recommend blood thinner or cholesterol-reducing drugs to minimize post-surgical complications.

Your healthcare provider will also teach you how best to care for the surgical wound.

Such care promotes faster healing and reduces the risk of infection.

Your surgeon may recommend a cardiac rehabilitation program as part of your recovery journey.

Cardiac rehabilitation encompasses guided exercises to promote heart function.

The surgeon may also encourage you to reduce the risk factors for developing heart disease.

You may have to adopt a healthy diet, quit smoking, and manage your stress levels.

Having control over your cholesterol level and blood pressure is also vital for a successful cardiac rehabilitation program.

Certain patients report experiencing mood swings and episodes of depression after CABG surgery. For such patients, there is a need to incorporate mental health treatment as a means to promote recovery.

Lifestyle modification is also vital for a successful recovery following CABG.

While the procedure helps to restore blood flow, there is the risk of a recurrence of the condition.

There is a need to closely follow the guidance of your healthcare provider on how best to improve your lifestyle.

This may entail incorporating physical activities and dietary modifications into your daily life.

Post-op emergency 

If you experience one or more of the following symptoms after surgery, reach out to your healthcare provider immediately:

• If you are having trouble breathing

• In case of heart palpitations

• If you develop chest pain

• If your speech gets distorted or slurred

• In case you have fainted

• If you develop a fever

• In case you are feeling lightheaded

Cost of CABS in India 

Indian hospitals offer CABG procedures at competitive rates compared to other parts of the world, including Europe and the United States.

The cost ranges between Rs. 95,000 and 4,50,000.

The difference in prices is based on various factors:

• Individual cities

• Choice of hospital (public hospitals are cheaper than private facilities)

• The surgeon’s experience and skill level

• Surgical fees and other fees by the healthcare team

• Length of stay in hospital

• Whether the surgery is conducted in an outpatient facility

• The cost of diagnostic tests

• Cost of medication

Considerations in choosing a facility for CABG in India 

India has highly advanced healthcare facilities that perform CABG procedures.

These healthcare facilities have invested in the latest diagnostic and surgical equipment, while surgeons are highly qualified and competent.

Choosing a treatment facility in India that is best suited for your CABG can be challenging for international patients.

Below are important considerations to help you make the most informed decision:

• Accreditation and quality certifications

• Whether the healthcare facility offers transportation to and from the hospital

• Experience and qualification of your surgical team

• Type of diagnostic and therapeutic equipment available

• Check if the hospital provides assistance to international patients, such as visa

• Processing and accommodation

References

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