Who is a candidate for minimally invasive bypass surgery

Hillis LD, Smith PK, Anderson JL, et al. 2011 ACCF/AHA guideline for coronary artery bypass graft surgery: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2011;124(23):e652-e735. PMID: 22064599 pubmed.ncbi.nlm.nih.gov/22064599/.

Mick S, Keshavamurthy S, Mihaljevic T, Bonatti J. Robotic and alternative approaches to coronary artery bypass grafting. In: Sellke FW, del Nido PJ, Swanson SJ, eds. Sabiston and Spencer Surgery of the Chest. 9th ed. Philadelphia, PA: Elsevier; 2016:chap 90.

Omer S, Cornwell LD, Bakaeen FG. Acquired heart disease: coronary insufficiency. In: Townsend CM Jr, Beauchamp RD, Evers BM, Mattox KL, eds. Sabiston Textbook of Surgery. 20th ed. Philadelphia, PA: Elsevier; 2017:chap 59.

Rodriguez ML, Ruel M. Minimally invasive coronary artery bypass grafting. In: Sellke FW, Ruel M, eds. Atlas of Cardiac Surgical Techniques. 2nd ed. Philadelphia, PA: Elsevier; 2019:chap 5.

Page 2

Most people who have quit smoking were unsuccessful at least once in the past. Try not to view past attempts to quit as failures. See them as learning experiences.

It is hard to stop smoking or using smokeless tobacco, but anyone can do it.

Know what symptoms to expect when you stop smoking. These are called withdrawal symptoms. Common symptoms include:

• An intense craving for nicotine
• Anxiety, tension, restlessness, frustration, or impatience
• Difficulty concentrating
• Drowsiness or trouble sleeping
• Headaches
• Increased appetite and weight gain
• Irritability or depression

How bad your symptoms are depends on how long you smoked. The number of cigarettes you smoked each day also plays a role.

FEEL READY TO QUIT?

First, set a quit date. That is the day you will quit completely. Before your quit date, you may begin reducing your cigarette use. Remember, there is no safe level of cigarette smoking.

List the reasons why you want to quit. Include both short- and long-term benefits.

Identify the times you are most likely to smoke. For example, do you tend to smoke when feeling stressed or down? When out at night with friends? While drinking coffee or alcohol? When bored? While driving? Right after a meal or sex? During a work break? While watching TV or playing cards? When you are with other smokers?

Let your friends, family, and co-workers know of your plan to stop smoking. Tell them your quit date. It can be helpful if they know what you are going through, especially when you are grumpy.

Get rid of all your cigarettes just before the quit date. Clean anything that smells of smoke, such as clothes and furniture.

MAKE A PLAN

Plan what you will do instead of smoking at those times when you are most likely to smoke.

Be as specific as possible. For example, if in the past you smoked when drinking a cup of coffee, drink tea instead. Tea may not trigger the desire for a cigarette. Or, when you feel stressed, take a walk instead of smoking a cigarette.

Get rid of cigarettes in the car. Put pretzels there instead.

Find activities that focus your hands and mind, but make sure they are not taxing or fattening. Computer games, solitaire, knitting, sewing, and crossword puzzles may help.

If you normally smoke after eating, find other ways to end a meal. Eat a piece of fruit. Get up and make a phone call. Take a walk (a good distraction that also burns calories).

CHANGE YOUR LIFESTYLE

Make other changes in your lifestyle. Change your daily schedule and habits. Eat at different times, or eat several small meals instead of three large ones. Sit in a different chair or even a different room.

Satisfy your oral habits in other ways. Eat celery or another low-calorie snack. Chew sugarless gum. Suck on a cinnamon stick. Pretend-smoke with a straw.

Get more exercise. Take walks or ride a bike. Exercise helps relieve the urge to smoke.

SET SOME GOALS

Set short-term quitting goals and reward yourself when you meet them. Every day, put the money you normally spend on cigarettes in a jar. Later, spend that money on something you like.

Try not to think about all the days ahead you will need to avoid smoking. Take it one day at a time.

Just one puff or one cigarette will make your desire for cigarettes even stronger. However, it is normal to make mistakes. So even if you have one cigarette, you do not need to take the next one.

OTHER TIPS

Enroll in a stop smoking support program. Hospitals, health departments, community centers, and work sites often offer programs. Learn about self-hypnosis or other techniques.

Ask your health care provider about medicines that can help you quit nicotine and tobacco and keep you from starting again. These include nicotine patches, gum, lozenges, and sprays. Prescription medicines that help reduce nicotine cravings and other withdrawal symptoms include varenicline (Chantix) and bupropion (Zyban, Wellbutrin).

The American Cancer Society's website, The Great American Smokeout is a good resource.

The website smokefree.gov also provides information and resources for smokers. Calling 1-800-QUIT-NOW (1-800-784-8669) or 1-877-44U-QUIT (1-877-448-7848) will direct you to a free telephone counseling program in your state.

Above all, do not get discouraged if you are not able to quit smoking the first time. Nicotine addiction is a hard habit to break. Try something different next time. Develop new strategies, and try again. For many people, it takes several attempts to finally kick the habit.

The benefits of minimally invasive CABG over traditional surgery include the following:

• Less pain
• Lower risk of infection and other surgical complications
• Lower risk of stroke and arrhythmia
• Less blood loss and reduced need for blood transfusions
• Shorter surgery time and less time under anesthesia
• Shorter hospital stay
• Faster recovery time and quicker return to normal activities
• Better aesthetic results (smaller scars)

Who may benefit

Most candidates for bypass surgery stand to benefit from this minimally invasive option. That's especially true for patients at higher risk from open-heart surgery because of age, frailty or other health conditions – such as obesity, diabetes and chronic obstructive pulmonary disease (COPD) – or because they are immunocompromised.

This procedure is not for all bypass patients, however. Prior surgery on the chest or lungs, radiation therapy to the chest, or intrapleural chemotherapy can leave adhesions and scar tissue that can complicate the ability to access the heart. But these are not absolute contraindications. We make our decisions on a case-by-case basis after a full evaluation.

Evaluation

Your doctor will decide whether you're a candidate for minimally invasive CABG based on a number of factors, including:

• The presence and severity of heart disease symptoms
• The severity and location of the coronary artery blockages
• Your response to other treatments
• Your quality of life
• Any other medical problems you have

The evaluation process is much the same for minimally invasive CABG as for the traditional surgery. Your doctor will perform a physical exam focused on your cardiovascular system. Tests will be done to find out which arteries are clogged, the extent and location of the blockages, and whether your heart is damaged. These tests include:

• Electrocardiogram (EKG) – This simple test detects and records your heart's electrical activity. It's used to help detect heart problems and locate their source.
• Angiogram – A catheter (thin, flexible tube) is inserted into a blood vessel (usually in the groin area) and threaded through to the heart. A dye is injected through the catheter and special X-rays track the blood flow through your heart and arteries. The scan shows where the blockages are and whether your blood vessels are healthy and large enough to support a bypass.
• Left heart catherization – This is similar to an angiogram and may be done instead. A catheter is threaded through blood vessels to the heart and arteries, and dye is injected. The resulting X-ray images highlight blood flow through the arteries, allowing the doctor to locate blockages and determine whether your arteries are in good enough shape to support a bypass.
• Transthoracic echocardiogram (TTE) – In this noninvasive ultrasound scan, the transducer (the device emitting sound waves to produce images of your heart) is held against your chest. The test provides information about how well your heart valves and chambers are working and how blood is moving through.
• Arterial mapping – An ultrasound evaluation that is used to obtain detailed pictures of radial arteries (in the forearm) that may be used as bypass grafts. The graft vessels are obtained through an endoscopic technique that requires only a tiny incision at the wrist.

Procedure

The operation lasts from two and a half to three and a half hours. You are under general anesthesia (completely asleep). The team attending you includes your cardiothoracic surgeon, an anesthesiologist, other doctors, and nurses. If your doctor decides you need the support of a heart-lung machine, a perfusionist (a heart-lung bypass machine specialist) will also be present.

The surgeon makes a 2- to 2½-inch incision between ribs on the left side of the chest. Specialized surgical instruments are inserted through the incision, as well as an endoscope, a tube with a camera attached, which allows the doctor to see inside your chest. Muscles in the area are pushed apart. The surgeon finds and prepares an artery on the chest wall (the internal mammary arteries) and then attaches it to the affected coronary artery, just after the blockage. If there's more than one clogged artery, the process is repeated. Once all the bypasses are connected, the instruments are withdrawn and the incision is closed.

Patients with weak or dilated hearts may need to be on a heart-lung bypass machine during the surgery. However, the heart is not stopped, as it is in the traditional procedure. Your doctor will let you know ahead of time whether this is necessary.

Recovery

For the first 18 to 24 hours after surgery, you are in the cardiac critical care unit, where we can closely monitor your condition. You are then moved to a regular hospital room for another day or so. Most patients are discharged three days after surgery. You'll receive instructions on how to care for yourself at home.

One of the biggest advantages of minimally invasive CABG is the short recovery time. Most patients are free to move as they wish – they can even drive as soon as they leave the hospital. Most are cleared for all normal physical activities in 10 to 15 days, whereas recovery from traditional CABG takes three to four months.

As in traditional CABG, patients experience excellent results. Many remain symptom-free for many years, though clogs can develop in the grafted arteries or in arteries that weren't previously blocked. Lifestyle changes and medications can help prevent new blockages.

Risks

The minimally invasive procedure reduces the likelihood of some of the most common complications of traditional CABG. Because the incision is smaller and no bones are cut, the risk of bleeding during or after minimally invasive CABG is lower. There's less risk of stroke or atrial fibrillation because the heart is not stopped. Also, the smaller incision reduces the chance of infection.

The less common risks are about the same for the two approaches to CABG. These possibilities include pneumonia or breathing problems, pancreatitis, kidney failure and graft failure.