Off-Pump Coronary Artery Bypass Surgery

What is off-pump heart surgery? 

Off-pump heart surgery is a type of coronary artery bypass surgery done without the aid of a heart-lung machine.

CABG procedure ensures the normal flow of blood to your heart is restored.

The surgeon uses a graft (usually a vein or artery) to bypass the blocked artery. 

In open CABG surgery, a heart-lung bypass machine takes over the function of your lungs and heart. It means your heart is not pumping during surgery. 

With off-pump bypass surgery, the surgeon operates on you with the heart still beating.

Your surgeon will arrange for this procedure in advance. 

You may need off-pump CABG in case of a sudden blockage of your heart valve.

In the conventional off-pump CABG procedure, the surgeon makes a large incision through your breastbone. 

In recent years, a higher number of surgeons are opting for minimally invasive surgery. This type of surgery entails smaller incisions. Minimally invasive surgery has a faster recovery and is less painful. 

Who needs off-pump heart surgery?

If you have coronary artery disease (CAD), you may be a candidate for off-pump bypass surgery. CAD involves the accumulation of plaque in your arteries.

The plaque blocks or limits blood flow. Some symptoms of CAD include chest pain and shortness of breath. If an artery gets completely blushed, you are at risk of a heart attack.

Mild forms of CAD can be managed with medication and lifestyle modifications.

If you have severe CAD, you will need bypass surgery to minimize the risk of a heart attack.

The surgery also relieves symptoms of CAD. Some people respond better to coronary angioplasty as a treatment for severe CAD. Others are better off with off-pump coronary artery bypass surgery.

Talk to your surgeons to establish the best choice for you.

Explore the various benefits and risks of both treatments so that you can make the right choice.

Off-pump CABG may be more suited for certain individuals who may be considered high-risk by the healthcare provider.  These include people with chronic lung disease or kidney problems.

Persons with advanced aortic atherosclerosis are also considered high risk.

Since off-pump CABG is a highly delicate and sensitive procedure, you are better off considering a surgeon who is highly experienced in this procedure.

Preparing for off-pump bypass surgery

Your healthcare provider will provide you with instructions to assist you in getting ready for the procedure. If you are taking anticoagulants or certain other medications, you may be asked to stop taking them.

If you have a history,  of bleeding disorders, your healthcare provider would be interested in such information.

You will likely need to do blood work before surgery to determine the length of time needed for your blood to clot.

Let your provider know whether you are pregnant. If you are a smoker, the surgical team will ask you to stop.

You will be advised to fast for eight hours before surgery.  Usually, you are asked to avoid drinking or eating anything past midnight.

Before surgery

Your healthcare provider may order the following diagnostics or routine tests before surgery:

• Blood tests

• Chest X-ray

• Cardiac stress testing

• Electrocardiogram (ENG)

• Echocardiogram

Your medical team might decide to shave the area of the incision. About 60 minutes before the procedure, you will receive medication that relaxes you.

During surgery 

An off-pump CABG procedure starts with your anesthetist administering anesthesia. This will help you to fall into a deep sleep during surgery. 

The anesthesia ensures you do not feel any pain during surgery. It takes a few hours to administer this surgery. 

Your surgeon begins by making an incision on your leg or chest wall to remove a vessel. A chest wall vessel is preferred due to its ability to remain open for longer. This is the vessel that will be used as the bypass graft.

In case a minimally invasive off-pump CABG is the preferred type of surgery, your surgeon will need to make several small incisions between your ribs. 

The incisions permit the entry of robot-controlled arms.

The surgeon operates the robot arms to perform the surgery. 

As surgery is ongoing, your heart is still beating, the surgeon attaches one end of the graft to the aorta. 

The other end gets attached to the blocked artery. In this way, the graft bypasses the blocked section of the artery. 

Your surgeon will reconnect sections of your breastbone that had been separated.

The surgery team seals the site of the incision using staples or stitches. 

After surgery

You are shifted to the ICU (intensive care unit).

You are likely to feel confused due to the effects of the anesthesia.

You will be hooked to various tubes to drain blood and fluid from your chest.

A urinary catheter will be attached to your bladder to drain urine.

You will require assisted breathing via a tube inserted in your throat.

You are likely to have problems talking and feel uncomfortable with the tube in your throat.

After 24 hours, the surgical tube will be removed this tube.

You will feel soreness around the site of the incision.

In case of severe pain, notify your healthcare team immediately so that they can prescribe medication to manage this pain.

After 1 to 2 days following surgery, you should be in a position to sit up and make small movements.

Your surgeon may recommend breathing therapy to assist with the elimination of fluid that accumulates in your lungs.

After the surgical team has removed the breathing tube, you should be in a position to start taking fluids.

Your surgical team will closely monitor your progress to determine whether you should start taking regular food.

Most people who have undergone off-pump coronary artery bypass spend a few days in the hospital and then they get discharged.

The duration of stay in the hospital differs from one patient to another.

Have someone on standby to drive you home after you are discharged from the hospital like your spouse or a family member. You will also require help at home for a few days.

You may notice that you get tired too easily at first, but this should not worry you. You will soon regain your strength as you recover.

Do not engage in strenuous physical activities, until your healthcare provider gives you a clean bill of health. Avoid driving until your surgeon gives you a clean bill of health.

Your healthcare provider will organize a follow-up appointment to assess your recovery. This usually happens about 1 week after surgery.

During the follow-up appointment, the surgical team will remove staples or stitches on the incision. As part of your recovery, you may be recommended a cardiac rehabilitation program.

A cardiac rehab enables you to gradually regain your normal lifestyle. It involves simple walking, dietary modification, and adopting healthy habits that promote heart health.

Benefits of off-pump bypass surgery

Off-pump bypass surgery comes with several benefits for the patient:

• The incision made is smaller

• Recovery after off-pump bypass surgery is faster

• You remain in the hospital for a short duration

• A lower mortality rate relative to on-pump coronary artery surgery

• Fewer heart rhythm issues

Off-pump bypass surgery is also associated with the following postsurgical complications:

• Swelling

• Memory loss

• Stroke

• Infection

• Irregular heart rhythm

Some people are not suited for off-pump bypass surgery. Some people who have off-pump bypass surgery might require other bypass procedures in the future.

The surgeon who performs off-pump bypass surgery should be highly experienced. This minimizes possible complications that may accompany the procedure.

Risks/Complications

Off-pump bypass surgery has a high success rate.  The outcome is very promising for most people. However, it may involve certain risks:

• Infection

• Kidney failure

• Anesthesia-induced complications

• Bleeding

• Blood clot-induced heart attack or stroke

• Irregular heart rhythms

• Death

Some people are at a higher risk of developing complications after off-pump coronary artery surgery. These include the elderly and those with preexisting chronic conditions like kidney failure and diabetes.

Recovery

Recovery after off-pump bypass surgery is different for different patients.

Some of the factors that may affect your recovery from off-pump coronary artery surgery are:

• Overall health – If you have a preexisting chronic condition, this could delay your recovery

• Complications – If there were complications during the procedure, you might need additional medical attention. This will delay your recovery.

• Age – Elderly patients are likely to take longer before recovery compared to young patients

• Type of surgery – This will determine the size of the incision. If the incisions are small, recovery can be faster

Make sure you honor all the follow-up appointments by your surgeon.

In case you experience any of the following symptoms, contact your healthcare provider immediately:

• Rapid weight gain

• Excessive sweating or fever

• Chest or abdominal pain that gets worse with time

• Presence of swelling, redness, or pus around the incision site

• Irregular heartbeat

Cost of off-pump bypass surgery in India

It costs between Rs. 2,00,000 and Rs. 4,50,000 to undergo off-pump heart surgery in India. This is less than half what developed nations charge.

The cost of off-pump coronary bypass surgery in India varies depending on several factors:

• Type of hospital – Private hospitals charge more for the same procedure compared to public establishments

• Whether the hospital is accredited

• Type of surgery

• Patient’s diagnosis

• Technology in use

• The kind of sedation or anesthesia in use

• Room category

The table below is a summary of the average cost of off-pump heart surgery in top Indian cities:

Why you should consider Indian hospitals for your off-pump coronary surgery?

• The surgery rooms, ICU and recovery rooms are fully equipped with state-of-the-art equipment. Different Indian hospitals that offer off-pump heart surgery have adopted the latest technology in this procedure

• You will benefit from non-invasive assessment tests, including Stress echo and ECG

• The medical staff at Indian healthcare facilities is highly experienced in performing off-pump coronary surgery

Types of services available to international patients

International patients opting to have off-pump coronary surgery in India stand to benefit from the following services:

• Assistance with processing Visa and travel documents

• Consultations with your surgeon via video conferencing

• Detailed planning of your surgery including review of medical records

• Transport arrangements from the airport to your hotel

• Some hospitals also organize for your pick up from the hotel to the hospital for the surgery and back

• Continued follow-up by the hospital executives including after you go back home after surgery

References

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