http://cardiacsurgeryacademy.org/Electrocardiogram-andexercise-Stress-Test.

html Coronary Artery Bypass Grafting: CABG

Heart attacks, angina, and other problems occur as the result of narrowed or blocked arteries. In most instances, preventive medical treatments should be used initially. These may include dietary changes, weight reduction, treatment of diabetes and high blood pressure, exercise, and avoidance of smoking. However, in certain situations, coronary artery bypass surgery or a coronary angioplasty is appropriate. These situations include cases in which the symptoms do not respond to optimal medical treatment or when blockage of the coronary arteries is severe. What does Coronary artery Bypass grafting or CABG means? Bypass means an alternate route. A coronary bypass operation involves taking a short length of vein, usually from the thigh (the saphenous vein), and using it to allow blood to bypass the blockage in an artery. The internal mammary artery is also used as a graft. This artery lies inside the front of the chest. There is one on each side of the breastbone. The lower end of this artery is freed and sewn to the coronary artery beyond the blockage. The other end is left attached. Blood is thus rerouted into the coronary arteries. Other arteries as the radial artery and gastroepiploic artery can be used as a bypass graft also.

Before your surgery:

y

y y

You will be admitted the day of or day before your surgery. You will be given diagnostic tests, a physical examination, and will be seen by members of the cardiac surgery and anesthesia teams. A nurse will discuss the Intensive Care Unit (ICU), postoperative recovery and discharge planning procedures with you and your family. If you smoke, you should stop. Smoking constricts the coronary arteries, produces excess secretions in the lungs, raises blood pressure and increases the heart rate. The potential for complications increases after surgery if you continue to smoke. Blood thinners as aspirin, should be discontinued before surgery. In advance of your surgery, Blood will be prepared for you to be used whenever needed. Your cardiac surgeon will determine the amount required.Family members and friends may also donate blood for you if they meet eligibility criteria. Until midnight the day before your surgery, you may eat and drink as usual. After midnight, however, do not eat or drink anything. This helps decrease any

nausea and vomiting associated with anesthesia. If you have prescribed medications, use only a small amount of water. On the Day of Surgery Anesthesia Doctors will start to work on the Holding Area You will be transported to the pre-operative area outside the operating room one hour prior to surgery. Here, the anesthesia team will insert an intravenous line (IV) to sedate you. A local anesthetic is injected into the skin of the neck, and a larger catheter is introduced into the jugular vein and threaded through the right side of the heart into the pulmonary artery. This catheter, called a Swan-Ganz catheter, can be used not only to give medicines but also to measure cardiac and pulmonary-arterial pressure and the amount of blood that the heart is pumping. Although many heart surgical teams routinely use the Swan-Ganz catheter, not all of them do. It depends on the preference of the surgeon, the anesthesiologist, and the heart surgery team. Another catheter is then placed in one of the arteries so that the arterial blood pressure can be monitored and blood samples can be drawn to check the arterial bloods oxygenation level. This catheter is usually placed in one of the wrist arteries, often the radial artery. If a radial artery will be used for one of the bypasses, the other wrist can be used, or the catheter can be placed in the femoral artery by inserting it through the groin. Once the operating room team is prepared for your surgery, the anesthesiologist will take you to the operating room. You will be anesthetized (put to sleep); an endotracheal tube (breathing tube) will be inserted; and all your lines will be connected to a TV like machine to monitor your heart, blood pressure, respirations and other bodily functions. After sleeping a catheter is placed into the urinary bladder to calculate your urine output during surgery. Urine output is an excellent monitor for your kidney and heart functions. Now surgeons are ready to work: Your chest and legs are swabbed with antiseptic soap solutions, and sterile operating drapes are placed on and around the patient. Now the team is ready to make the first incisions, but immediately before this incision, a timeout is done. In this timeout the surgeon, anesthesiologist and nurses will reconfirm your name, your medical diagnosis and the type of surgery that will be performed. This is one of the important steps that prevent problems of the wrong patient and the wrong procedure. Usually one surgical team will make one or more shallow incisions in the leg and harvest the vein for the bypass while the other team opens the chest.

To open the chest, an incision is made in the skin. Beneath that, a layer of fat and muscle is cut through to expose the breastbone (sternum). A saw is used to open the entire length of the sternum. With the chest open, thee left internal mammary artery is freed. A blood thinner, called heparin is given intravenously into the bloodstream to prevent the blood from clotting while the circulation is supported by the heart-lung machine. The sac surrounding the heart is opened and the heart is exposed. Several plastic tubes are connected to the heart using special sutures. These tubes will then connect the patient to the heart lung machine. The tubes in the right atrium return unoxygenated blood from the patients venous system to the heart-lung machine. The machine will then oxygenate the blood and return it to the patient through one of the tubes connected to the aorta. After these tubes are in place, cardiopulmonary bypass is initiated by telling the technician or perfusionist running the heart-lung machine to turn on the machine. The heart-lung machine then takes over the function of the heart and lungs. After it is activated, most surgeons will cool the patients body temperature to some level, but not all surgeons do this. The heart is then stopped by a special solution called cardioplegia. With the heart stopped and the body supported by the heart-lung machine, the coronary arteries that are to be bypassed are identified. The coronary arteries are opened beyond the obstruction and measured. With the coronary opened beyond the area of obstruction. One end of the graft is hooked to the coronary artery with small stitches usually made out of polypropylene. After all the bypasses, are sewn to the coronaries, the other ends are joined to the aorta or, in some cases, to other veins or arteries. If the internal mammary artery is used, one end is already connected to the arterial system. The bypasses are now complete and the patients body is rewarmed. The heart usually restarts on its own but sometimes needs the help of a temporary pacemaker or an electrical shock. After the heart has started, the patient is weaned from the heart-lung machine by slowly turning the heart-lung machine off as the patients own heart and lungs take over. In some cases, the heart is too weak to take over for whatever reason, and another attempt or two will be made at letting the heart take over. If these are unsuccessful, an intra-aortic balloon pump is used, which is a pump that is threaded through an artery, usually through the groin, and connected to an external power

source. There is a balloon on the tip of a long, thin tube that inflates and deflates in synchrony with the heart, helping the heart to pump blood as well as increasing the blood going to you coronary arteries. In more severe cases when the heart does not take over, some form of ventricular assist device may have to be used. This is relatively uncommon. Most patients are weaned from bypass without the use of any type of mechanical support on the first attempt. The operative field is revised for any bleeding points which are secured. The sternum is then closed with permanent stainless steel wire. The muscle and skin are then closed. Now your surgery is over and you are ready to be transferred to the ICU .

Coronary Angiogram Or Angiography

In diagnosing coronary artery disease, it is invaluable to be able to "see" the coronary arteries and the shape and function of the heart chambers. Coronary angiography is a procedure in which a special X-ray of your hearts arteries (the coronary arteries) is taken to see if they are narrowed or blocked. It is an important test, used when your doctor suspects or knows that you have coronary heart disease. The procedure for making an angiogram involves insertion of a catheter (a hollow, flexible tube) into an artery at your groin or elbow. This catheter is guided through your main artery, the aorta, into your heart. Then it is guided into a coronary artery. A dye that is opaque to x-rays is injected through the catheter to make the inside of the heart and artery visible on an x-ray picture.

Angiography can be done on many blood vessels in the body, but when it is done on heart arteries (coronary arteries) the test is called coronary angiography or cardiac catheterization. In addition, the catheter can be placed in the left side of the heart where the function of the mitral and aortic valves can be studied; the shape and function of the left atrium and the left ventricle of theheart also can be observed. Before the catheterization begins, you will receive a mild sedative, but you will remain conscious during the procedure. Leads (wires) of an electrocardiograph machine will be placed on your chest so that your physician can monitor the action of your heart throughout the test. A needle attached to a tube and bottle of 5 percent dextrose in water will be placed in your vein. An artery in your arm, leg, or groin will be selected for insertion of the tube (catheter that is to be gently guided into your heart or other area. The insertion site is cleansed with an antiseptic and draped in a sterile fashion. A local anesthetic is injected into the skin and deeper tissues; there should be no further pain after this. When the catheter is in place, a contrast medium (dye) will be delivered through the catheter to your coronary arteries to provide a clearer x-ray picture. If your physician also wants to widen your blood vessels you may be asked to hold a nitroglycerine

tablet under your tongue. At certain times you will be asked to take deep breaths, which improves the quality of the x-ray pictures that are made during the examination.

Results of the catheterization are monitored on a television screen during the test. These video images are also recorded on a CD for further study and for your own records.Then the catheter is removed and the examination is complete. For the first 20 to 30 minutes after removal of the catheter, direct pressure is placed on the insertion site. You will be kept in bed for at least 4 hours. Your vital signs will be checked periodically. lf needed, you will also be given pain medication, and the insertion site will be checked for soreness,swelling, or blood loss. In most circumstances, you will be allowed home after four to six hours. Some people may need to stay in hospital longer so that their symptoms can be monitored further. Your doctor will explain the results of the test. The information about your heart and coronary arteries will help your doctor to recommend the best treatment for you.

Although this is a common procedure, some risks are associated with it. For example, if the catheter loosens an existing blood clot or cholesterol deposit within an artery, the result can be a stroke or heart attack. In rare instances, the heart or kidneys can be damaged. Anyone with a blood clotting disorder or poor kidney function is at increased risk. Still, the risk of a serious complication (such as stroke, heart attack, or even death) is approximately 1 in 1,000. The risks are lowest in young, healthy persons and highest in older persons with serious medical problems. Because of risks associated with this test, a surgical team usually is available during the catheterization procedure and can be called upon in the event surgery is required.

It is worth mentioning that Angiography can also be used to evaluate the right side of the heart and pulmonary arteries. In this case it is called right heart or pulmonary artery angiography. To study the right atrium and ventricle and its valves (tricuspid and pulmonic) or the pulmonary arteries, a catheter can be placed in a large vein in your leg or arm and advanced into your heart or into the main artery of your lungs (pulmonary artery). Contrast medium (dye) is then injected through the catheter and an x-ray picture of your pulmonary arteries is produced. This is usally used in kide to diagnose some complex congenital heart diseases. If a blood clot is discovered during the procedure, it is usually treated with a powerful anticoagulant drug. Rarely is surgery required to remove a blood clot in the pulmonary arteries.

Chest X-ray
Despite the availability of many new imaging techniques, X-rays are still a widely used and valuable means of seeing inside the body. X-rays are a form of invisible electromagnetic radiation of short wavelength; they are closely related to both radio waves and light waves. Doctors know to what extent each of the bodys tissues absorbs X-rays. The less dense a substance is, the greater the ability of X-rays to pass through it. In the body, soft tissues such as skin, fat, muscle, and blood are more transparent to X-rays than

hard, dense substances such as bone. Thus, when a beam of X-rays is directed at a part of the body, the chest for example, X-rays pass easily through the soft tissues but do not penetrate the ribs and the breastbone, which cast a shadow. Because X-rays blacken photographic film, the shadow of the bone appears as a white area; the soft tissues (heart and lungs) are represented on the film as dark gray. X-rays are produced using electric power in a device called an X-ray tube. The X-rays travel in straight lines, radiating outward from the target, and emerge as an X-ray beam from a small aperture in the lead casing that surrounds the Xray tube. The beam is focused on a part of the body placed against an Xray cassette. When the film is processed, the body parts that allowed few X-rays to pass through appear white; those that transmitted many rays appear black. X-rays give a photographic image of part of the body. This image may confirm or rule out the doctors diagnosis. The simplest type of X-ray examination is a single "snapshot" image. These plain X-ray pictures are an excellent means of showing bone and dense areas in the body, such as tumors, and are commonly used for examining the chest, skull, spine, and other parts of the skeleton. When you arrive for an X-ray, the X-ray technician or radiologist will explain the procedure and will position you in contact with a cassette containing the X-ray film. You will be asked to remain very still during the period of exposure (which usually lasts less than a second), since any movement produces a blurred image that is difficult to interpret. When all is ready - you are in the correct position, the film is in place, and the machine has been set to the right exposure, the technician moves briefly behind a protective screen (from which he or she can still see and talk to you) and presses the exposure button. You will not feel any sensation; X-rays are painless. Several X-ray pictures are usually taken from different angles to get as complete a view as possible of the area in question. The technician will alter your position and that of the equipment as required between shots. As soon as the pictures are taken, the films are passed into an automatic developing machine and are developed, fixed, and dried within a few minutes. If there is reason for urgency, the films are examined immediately by a radiologist. However, in most cases, the radiologist reviews your films later in his or her office, writes a formal report, and discusses the results with your doctor. X-ray images of the heart and circulatory system allows doctors to investigate a wide range of disorders. A chest X-ray is a simple method of obtaining an image of the heart. Having a chest X-ray is a quick and painless procedure that is usually done on an outpatient basis. A chest X-ray reveals the size, shape, and position of the heart and the large blood vessels that carry blood in and out of the heart chambers. Disorders

that can be detected include enlargement of the heart chambers, ballooning of the upper part of the aorta, and expansion of the heart outline from accumulation of fluid in the pericardial sac.

A chest X-ray can confirm that the heart is failing to keep up with its work load by revealing accumulation of blood in the vessels, the presence of fluid inside the lungs, or an enlarged heart. With routine chest x-ray pictures, doctors can frequently tell if calcium has collected on the heart valves or in the aorta or can even see calcium in coronary arteries. Calcium deposits may suggest certain types of disease. They can also determine how effective a certain treatment is in improving heart failure and decreasing lung congestion. Compared with some of the sophisticated imaging methods used today, the information gained from a chest X-ray is considered one dimensional.

Percutaneous Transluminal Coronary Angioplasty (PTCA)

Narrowed or blocked arteries may produce a heart attack , angina , or other problems. In some cases a special diet or medication or both may be the best treatment for such arterial problems; in other cases, bypass surgery or coronary angioplasty may be the

best answer. The full name for coronary angioplasty is percutaneous transluminal coronary angioplasty (PTCA). This means that, through the skin (percutaneous), a procedure is performed inside an artery (transluminal) of the heart (coronary) that reshapes (angioplasty) that artery. The procedure is simpler than its name. PTCA is performed with local anesthesia while you are awake. This procedure is quite like the diagnostic procedure called coronary angiography. Before the procedure: You need to have a shower or bath on the morning of your angioplasty. This will make sure your groin area is clean and help to reduce the risk of infection. You will also need to shave your right groin area. You should have a light breakfast before 6am on the day of your angioplasty. You must not eat anything else until after the procedure. You should however drink fluids freely until you have your angioplasty and continue to drink plenty of fluids for 12 hours afterwards. On the day of the procedure: When you arrive at the ward you will be seen by a doctor or nurse who will take your medical history, perform a medical examination and insert a small tube (cannula) into one of the veins in your hand or arm for any medicines you may need. You will also have some blood taken for routine blood tests and a routine ECG (electrocardiogram ). Procedure: After a local anesthetic is injected into your groin or shoulder area, the physician inserts a hollow, flexible tube, called a guide catheter, into a leg or arm artery. While watching on a TV monitor that displays an x-ray image of the blood vessel and catheter, the physician guides the catheter into the narrowed coronary artery. Fluid called contrast dye will be injected through the catheter into your heart arteries. This fluid can be seen under x-ray, so your doctor will be able to view and take pictures of your heart arteries before, during and after your angioplasty. A smaller catheter is then inserted inside the guide catheter. This one has a balloon at its tip. When the catheter tip reaches the area of obstruction in the coronary artery, the balloon is inflated for about half a minute to widen the obstructed part of the artery. While it is inflated, you may feel chest pain; when it deflates the pain will fade. Several inflations and deflations usually are necessary.

Then the balloon catheter is removed, and more x-rays (angiograms) are taken to see how blood flow has improved. The entire process usually takes between 30 and 90 minutes. The procedure also may be used to treat blocked arteries elsewhere in the body, including the legs. An angioplasty is usually performed through the large artery in your groin. Some cardiologists prefer to do this procedure through a blood vessel in your arm. The procedure is very similar. Your cardiologist will explain this to you in more detail if this method is chosen. In a small percentage of cases, the procedure is unsuccessful and bypass surgery is necessary; usually, a surgical team is available to proceed immediately. When the angioplasty alone is successful, the need for major surgery and the use of a heart-lung machine are avoided. Recovery and Rehabilitation: For 24 hours after the procedure, your heart rate and rhythm and other vital signs will be closely monitored. Because the procedure involves insertion of a small catheter through the skin, the incision is small and many people go back to work a week after the procedure. Your doctor will usually explain the results of your procedure to you immediately after it is finished, or he/she will come to see you once you are back on the ward. You will be taken to the recovery area for about 20 to 30 minutes and then back to your ward.

The sheath is commonly left in place as we need to wait for the heparin (a blood thinning medication used during the procedure) to wear off. It is very important to lie flat, keeping your leg straight whist the sheath is in your leg. After taking a blood test to check that the heparin has worn off (about 3-4 hours after you have returned to the ward) your nurse will remove the sheath. This will be done either by applying firm pressure to the area for about 15-20 minutes or by using a special device that puts firm pressure on your groin for about an hour. This may be uncomfortable, but is necessary to stop the bleeding. Who Is a Candidate for PTCA? People whose angina has not been relieved by medications are candidates for this procedure. The ideal candidate has only one narrowed artery, although many persons with several areas of narrowing can undergo PTCA. The decision to recommend PTCA rather than bypass surgery is based on the location, number, and severity of blockages as well as on the overall function of the heart. However, the procedure does not cure the underlying disease. In fact, the procedure may have to be repeated to reopen the same or another coronary artery that becomes blocked. In future years, physicians may be able to remove plaque by using laser light or mechanical devices. Wound care It is normal for your groin to be tender for a few days after the angioplasty. It is also normal for a bruise to develop. However, if you notice any of the following please contact your doctor:
y y y y

A hard tender lump under the skin around the area of incision. Pain, swelling, redness and/or discharge at the site A cold foot on the same side as the procedure. A raised temperature/fever.

If your groin starts to bleed you should lie down and apply pressure to the area keeping your leg as straight as possible. If the bleeding does not stop after 10 minutes dial 911.

A polypropylene suture is a synthetic monofilament plastic thread used for wound closure in many surgical procedures. The material used to make the suture is resistant to colonization by bacterium. Its smooth surface texture helps prevent tissue damage from occurring as wounds are

sutured closed. The suture has a very high tensile strength to prevent it from rupturing after being used for wound closure. Several medical procedures make use of the polypropylene suture. Plastic surgeons use them during breast augmentations and reductions. They can be used in cardiovascular surgery and orthopedic operations, and are also gentle enough to be used in ophthalmic procedures without damaging the delicate tissue of the eye. These sutures can also be used in previously infected and possibly contaminated wounds. A polypropylene suture is composed of a thermoplastic that is inert when it comes into contact with bases, acids, or solvents. Polypropylene may begin to degrade after exposure to ultraviolet (UV) light. The sutures should be stored in a cool dark place to extend the shelf life of the product. This synthetic suture material is colored blue for easy visibility against tissue during surgical procedures. The unique polypropylene material used in these sutures has anti-inflammatory properties to help eliminate tissue rupture. After the polypropylene suture is implanted within the body, the suture expands up to 30 percent. This prevents the tissue being stitched from strangulating if the suture tightens after placement. The additional positive blood flow may contribute to a faster healing time.