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Coronary Artery Bypass Surgery (CABG) - CABG provides direct, anatomic revascularization. CABG is standard cardiology's most effective, "sure thing" approach to coronary insufficiency. Here the problem is looked at as a supply:demand mismatch, a mismatch between the supply of oxygenated blood to the heart muscle and the demand of the heart muscle for oxygenated blood. CABG correct the mismatch. Superficial veins are removed from the surface of your legs, cleaned of surrounding tissues, and then a short segment of vein, reversed in orientation (veins allow only one way flow), is used as a bypass conduit. One end is sewn into the aorta, the great vessel that conveys oxygenated blood away from the heart. The other end is sewn into a diseased coronary artery, beyond its point of blockage, "bypassing" the blockage. Oxygenated blood is thus resupplied to a previously oxygen starved region of heart muscle. Energy production will normalize and your symptoms will resolve. Whenever possible, surgeons will utilize arterial grafts during CABG. The left internal mammary artery originates from the left subclavian artery (which goes on to supply the left upper extremity). The left internal mammary artery (LIMA) normally provides oxygenated blood to the left upper chest wall. When used as a bypass conduit, the proximal end of the LIMA is left attached to the left subclavian artery. The small side branches given off the LIMA to supply the chest wall musculature are tied off. The distal end of the LIMA is mobilized away from the chest wall and is then sewn into a coronary artery, usually the left anterior descending (LAD), "bypassing" the blockage. Blood flow will take the path of least resistance, so following bypass surgery the narrowing in the diseased but now bypassed native artery will often close, but that is not an issue, as the wide open graft will supply all the oxygenated blood that is required. The superficial leg veins were designed to transport deoxygenated, or "used" blood from the cells of the leg back to the heart, for later re-oxygenation as the used blood flows through the lungs. The superficial leg veins are actually responsible for only 15% of lower extremity return blood flow. The deep veins are responsible for the other 85%. They are left intact, so ankle swelling is typically not a problem following CABG in young people. Older patients may need to wear support stockings following bypass surgery, but this is not a huge price to pay. The real problem with vein grafts is that we are asking a vein to do an artery's job (more on this later). The chest wall also receives arterial blood from vessels that originate in the abdomen. Following bypass surgery that utilizes the LIMA, patients often note a vague discomfort over the chest wall. This sensation is sometimes difficult to differentiate from your prior angina, because it is mild "angina" of the chest wall, as it's blood supply has been reduced. This is not a threat and the discomfort is only minor, and is not a cause of worry.
The short term down side of CABG is the surgical risk, which varies with your age and overall health. Younger patients in otherwise good health cruise right through CABG and may be discharged home on their 5th post-operative day. Elderly patients in otherwise poor health are at risk for surgical complications involving their brain, kidneys, and other internal organs. Applying the principles of nutritional cardiology will unequivocally reduce your surgical risk and hasten your discharge from the hospital, but such therapies are forbidden in nearly all US hospitals. I am totally serious here - numerous studies published in peer reviewed cardiology journals tell us that agents such as magnesium, Co-enzyme Q10, vitamin C, and ribose lower mortality, reduce complication rates, and get you out of the hospital faster following CABG. However, their use is not permitted in our hospitals. If I wrote an order for Co-enzyme Q10 or vitamin C in a patient scheduled for CABG, the nurse would not honor it, the patients would be told that I wrote an order that was against hospital policy, and I would get a stupid phone call from the pharmacy technician telling me that these agents are "unproven homeopathic" substances. Dealing with this type of arrogance and ignorance is taxing. If I fight back, placing in the patient's chart the appropriate articles and writing notes about legal risk if the best therapy is not employed, then I would win the battle. The patient would receive the nutritional in question, and I will have made an enemy. I would have the fight the same battle, with the same people, with the next patient, and I would make more enemies. Retaliation would follow, sometimes not just against me. I have sent the appropriate articles to the hospital pharmacy and therapeutics committee and they would not even respond. Thus I have given up. If you want to know why I no longer personally manage my patients in the hospital, well now you know (in contrast, when I was 35 and intellectually confined to what I had been taught I was tied with two older guys as the leading cardiology admitter to my then primary hospital - now I know better and can not confine myself to drug only medicine). If I feel, based upon your symptoms, non-invasive work up, and heart catheterization that your need CABG, then I will coordinate your evaluation with a surgeon who I trust, and he will carry out the procedure. Your post-operative care will include cardiologists who I trust (competent and caring physicians who do not have my knowledge of nutritional medicine, such that they don't get into these fights). I will receive feedback from all involved prior to your 1st post-operative visit with me. We take great care (and pride) in our ability to "hand off" your case, such that all bases are covered.
The long term down side of CABG is the risk of graft closure. Our thin walled veins are designed to convey deoxygenated blood in a non-pulsatile, low pressure (5 mmHg) flow pattern back to the heart for reoxygenation. Placed in the chest as a bypass conduit, we are asking them to carry oxygenated blood in a pulsatile, high pressure (as high as your blood pressure) pattern. This high pressure stress in a high oxygen environment places intense free radical stress on the endothelial cells that line the vein graft. Endothelial dysfunction (impaired production of nitric oxide) follows, the vein walls become inflamed and they begin to fill up with plaque. The average vein graft lasts seven years, but 1/3rd close off within one year. Some of this is technical (if a vein graft is placed to a small artery it is more likely to close off as flow within the vein graft will sludge and the graft will close off), but much of vein graft disease is occurring on the basis of endothelial dysfunction, something that we can address. So far, agents that improve endothelial function in general, such as antioxidants, fish oil, the tissue specific ACE inhibitor Quinapril, and the statin class of cholesterol lowering drugs, have been shown to have favorable affects on vein graft patency and/or post-CABG outcome. The best time to start endothelial preserving therapy would be before your bypass surgery begins, continuing these agents within the immediate post-bypass period (when your new vein grafts are exposed to excessive free radical stress), but again, this type of logical therapy is not permitted in our hospitals. Thus I will get you started on or started back on these types of treatments as you recover. In contrast to vein grafts, the LIMA and RIMA vessels are native arteries. They are used to high pressure, high oxygen, pulsatile flow and their endothelial cells make a lot of nitric oxide. So while half of all vein grafts close within 7 years, 90% of all arterial grafts remain open at 10 years. Whenever possible, your heart surgeon will utilize the LIMA (and often the RIMA as well) as bypass conduits for your CABG.
The technique of CABG is continually evolving, aiming to improve the technical aspects of the procedure, such that your outcome is improved. Two recent advances bear mention. Traditional "on pump" bypass was carried out on a bloodless, arrested heart. Your heart would actually be stopped, with your brain and other internal organs supplied by blood that was conveyed through the bubble pump oxygenator. Tiny clots could form in the bubble oxygenator and get stuck in your brain. This delayed your recovery from CABG, and in extreme cases left you with impaired intellectual function. Recent technical advances allow surgeons to operate "off pump", on a still beating heart. The bubble pump oxygenator is no longer necessary, blood flow to your brain is no longer impaired, and you recover much faster from the procedure. "Off pump" CABG has been a major advance. Transmyocardial laser revascularization, otherwise known as TMR, is the second major breakthrough. If your surgeon places a vein graft to a small or diffusely diseased (the whole vessel is full of plaque) coronary artery, flow through that vein graft will be sluggish and the graft will likely fail. If all of your arteries are small or diffusely diseased, you will be deemed "inoperable" and you will be turned down for CABG. Your surgeon will not operate if the procedure is obviously doomed to fail. But what if 1-2 of your arteries could be grafted, but 1-2 are inoperable? Does the surgeon do 1/2 the job, placing grafts to the operable vessels while ignoring the small ones? In this situation you could easily experience a heart attack involving the heart muscle served by the non-bypassed vessels. On the other hand, if he doesn't operate, your chest pain will continue and you will eventually experience a heart attack(s) on your own - what a dilemma! TMR allows effective revascularization in this situation. Tiny channels are "drilled" into the heart muscle with a medical laser. As the heart heals these laser channels, a capillary blood supply will develop, and some degree of revascularization will occur. TMR is typically not done as a stand alone procedure (the results are not satisfactory when all three vascular distributions are inoperable and TMR is used instead). TMR works great in the situation where 1-2 vessels can be bypassed, and 1-2 cannot. TMR can also serve as a bridge between CABG and EECP. I recall a patient with severe angina and a poorly operable situation who underwent CABG combined with TMR. Six months later he returned with more pain. I repeated his angiogram and found two open and tow closed vein grafts. A heart attack had not occurred, because his surgeon had carried out TMR on the heart muscle supplied by the diffusely diseased arteries. The TMR effect was not strong enough to keep the patient pain free, but it was enough to prevent a heat attack when the two grafts failed. We had anticipated that the grafts to these vessels might fail, so TMR was carried out concomitant to CABG. EECP was carried out and the patient did great. EECP as a primary or initial procedure would have failed, as all the vessels serving this patient's heart were diseased. This program was actually planned out in advance by myself and the heart surgeon who I work most closely with (wouldn't it be neat if I could get the rest of his hospital to work with me - well maybe in 10 years)!
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