Ask the Heart Doctor: State-of-the-Art Coronary Artery Bypass Surgery

Podcast Transcript

Announcer:

Welcome to Love Your Heart, brought to you by Cleveland Clinic's Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute. This podcast will explore disease prevention, testing, medical and surgical treatments, new innovations and more. Enjoy.

Faisal Bakaeen, MD:

Okay, so we've decided that a patient is a surgical candidate from an anatomy standpoint and they can tolerate surgery. Now, we're going to talk through how we proceed with traditional, let's start with traditional CABG. Maybe you could start with that, Tarek, and then Donna could talk about the robotic-assisted minimally invasive approach. Explain to our patients how we do the bypass surgery in the OR.

Tarek Malas, MD:

Dr. Bakaeen gave a fantastic overview about what we do when we assess a patient. It's a complex decision that's made between the patient and the physician, and after a lot of extensive testing to know that the patient's finally a candidate, then the next step is taking to the operating room. In a majority of cases, coronary artery bypass grafting, especially of multiple grafts, is done through a sternotomy. A sternotomy is basically an incision in the center of the breastbone. That allows us to access the heart. Once we have access to the heart, we can visualize the vessels directly on the heart, and the next step is to bypass the arteries that require bypass. That can be done through two different approaches.

That can be done with the assistance of something called the heart-lung machine, which is a machine that supports the heart and the lungs, and that allows us to do some bypass. That can also be done in an off-pump setting, meaning we can do surgery on a beating heart, and that's a fantastic operation as well. What we do is basically attach these grafts or conduits to an area of the artery that is past the blockage, and that allows us to supplement the circulation. Bypass surgery can range from one, two, three, four, five bypasses or more. That really depends on the anatomy, the conduits and the type of disease that the patient has.

Faisal Bakaeen, MD:

What conduits do you prefer in general, especially for younger patients or patients with a prolonged life expectancy?

Tarek Malas, MD:

We are a strong advocate of multi-arterial grafting here at the Cleveland Clinic. What multi-arterial grafting means is using more arteries than veins. There's strong evidence that suggests that arteries last longer than veins, especially in the most important artery, the left internal mammary artery that sits on the underside of the sternum. There's significant evidence that shows that it really prolongs life.

There are two arteries in the chest wall. We prefer to optimize use of multiple arteries, even the radial artery in the arm, over using conduits such as veins. If you look at national data, not many centers do a lot of multi-arterial grafting, and we should be definitely more of a proponent of that. That's something that we hold very dearly here at the Cleveland Clinic that shows the multi-arterial grafting actually improves survival in the long term for patients.

Faisal Bakaeen, MD:

It really started here with Dr. Loop back in 1986, where he published a seminal article in the New England Journal of Medicine showing that if you use an internal thoracic or internal mammary artery, that stays open in perpetuity and prolongs the life of the patient. It became the gold standard when you perform CABG, coronary artery bypass grafting. Then after that, Dr. Lytle in the late nineties demonstrated that if one is good, then two must be better. He was absolutely right. In many of our patients, the default approach is to use multiple arteries. This is the traditional approach that we offer to patients, but there are patients who are suitable for a minimally invasive approach.

You talked a little bit, Donna, about what kind of workup you use, and once you determine that the patient is a suitable candidate for a minimally invasive approach, talk us through how you do it.

Donna Kimmaliardjuk, MD:

Right, when we do a minimally invasive approach, what we mean is it's a small incision. It’s usually about the length of a credit card that's on the left front of the chest. It's usually under the areola in a man and/or a woman. For a woman, it's just above the inframammary fold. Through that cut, that's where we actually do the bypass.

Faisal Bakaeen, MD:

Right underneath the breast.

Donna Kimmaliardjuk, MD:

Right underneath, yes, for a woman. That's where we do the bypass. You and I have done this before we had the robot, through that little cut. We would actually detach or peel off the left internal mammary artery from the ribcage through that little cut. It's very technically demanding because I always tell people, "You're working through a little hole and a little tunnel. You're working down here, you’ve got to get all the way up here to get that artery down." So, I still do that approach, you still do that approach if indicated. But with the robot, what makes it a bit easier is there's better visualization, as you know. But in order to use the robot, we then have to make three separate little incisions, usually about a centimeter or so in width, so that we can actually get the arms and the camera of the robot into the patient, so we can work the robot.

Those three incisions are on the far left side of the chest between the ribs. They are usually a couple of rib spaces apart between each of those three cuts. You have those three small cuts on the far left side of the chest, and then you have a slightly bigger cut on the front of the chest on the left side. With those three incisions, you're able to do that minimally invasive bypass.

Faisal Bakaeen, MD:

So, basically three keyholes. The middle one is for the camera, and then two working ports, one above and one below it, and you're taking down the vessel. The advantage of the robot is that you have enhanced visualization. You have 10 times the magnification, so there's precision, there's accuracy and perhaps there's less spreading of the ribs. Because without the robot, you've got to spread those ribs to see and take it down under direct vision. You could take a longer mammary, internal mammary with the robot, you could spread the ribs less so you cause less pain. Then once the mammary is down, you actually do the actual sewing with your own hands through that credit card incision that you made.

Donna Kimmaliardjuk, MD:

Yes.

Faisal Bakaeen, MD:

Mine might be a little bit more than the credit card. It depends on the size of the patient.

Donna Kimmaliardjuk, MD:

Depends on the patient.

Faisal Bakaeen, MD:

The bigger patient will need a little bigger hole.

Donna Kimmaliardjuk, MD:

A little bit bigger. Yeah.

Tarek Malas, MD:

The benefits of robotic surgery are incredible because it's such an incredible tool. Like Dr. Bakaeen said, the magnification is superb. You get to view the robot very well, and there are these three slender tubes that go in between the ribs rather than having to do, for example, any bone cutting. We don't do that in robotic surgery. That really improves the recovery of the patient and has a fantastic cosmetic result as well.

Faisal Bakaeen, MD:

When you do the bypass, you do it with the heart beating, you don't go on the heart-lung machine?

Donna Kimmaliardjuk, MD:

Correct. I do it with the heart beating.

Faisal Bakaeen, MD:

Neither do I. Yes.

Donna Kimmaliardjuk, MD:

I think talking with other folks across the country, that tends to be most common, that we do it with the heart beating. The nice thing about doing that one bypass to the left anterior descending artery, that's really the artery that we're treating. It's right on the front of the heart, so it's usually right under where we've made that incision, so we can see it very nicely. I also do sternotomy approaches without the heart-lung machine a majority of the time. That's also why I do this minimally invasive without the heart-lung machine.

Faisal Bakaeen, MD:

So, the heart is beating like that, and you're going to sew on that vessel. How do you do that with the heart doing this? I know how to do it, but tell our audience.

Donna Kimmaliardjuk, MD:

So, there's specific tools and instruments made to facilitate working on a moving target that also has blood being pumped through it. Once we have taken that mammary artery off of the rib cage, you then what's called “undock” or take out the robot, you don't need it anymore because now we're going to sew the actual bypass by hand. Then through one of those holes that you made, you can put this stabilizer device. It's two little arms that have suction on them that you then place onto the heart on either side of the blood vessel that you're going to sew onto, right in the area that you're going to sew onto. The whole heart's moving, but because this little suction device is attached to the heart, this part of the heart moves a little less, so it makes it a little bit easier to sew onto that moving target.

Then, there's sutures that we can use to temporarily occlude blood flow through that artery when we open the artery to actually sew onto it, so you don't have as much blood coming through it. Then what my practice is, and I think a lot of other surgeons’ practice is that do this beating heart, is we put in something called a shunt. It's a very small little plastic tube. They're very soft and they come in different sizes based on the size that's going to fit that artery. Through the opening that you've made on the artery where you're going to actually sew your bypass, you then insert the little shunt proximally, so before the opening and distally beyond the opening, and then you can remove the sutures that are occluding or closing off that artery. Now it's pretty cool. You have blood flow going through your coronary artery through that little plastic tube. It's like a tunnel, and then continuing on distally to the remainder of the artery. You have blood flow going through it the whole time as you're doing the bypass.

I think it's very, very safe because you're getting blood flow to that whole part of the heart. I sometimes say it's almost like the heart's none the wiser that anything's going on. I just sew, and you guys too, just sew around that little shunt as I'm doing my sutures to sew on my artery onto the heart for the bypass. Then, right before you've done your last suture, you can pull that little shunt. It's very soft, as I mentioned, so it comes out nicely. Then you tie down your bypass. There are specific tools that are made to make it a little easier.

Faisal Bakaeen, MD:

So, it has to be perfect. I know that you are a very skilled surgeon and you make perfect bypasses, but how are you 100% confident after you finish sewing this in a traditional and a minimally invasive approach that this anastomosis is actually perfect?

Donna Kimmaliardjuk, MD:

We are big proponents, the three of us, of using that ultrasound probe. There's a little ultrasound probe that can actually measure the flow through the bypass and also the resistance to the bypass graft. Based on the flow, the actual milliliters per minute and the resistance, that will tell me if I'm happy with the bypass, if it's an excellent bypass or if I'm concerned about it and I should redo it or adjust something. I think that's really been a fabulous tool, a very helpful tool.

Faisal Bakaeen, MD:

Right. Hopefully, if you chose your conduits well and you did a technically perfect operation like we always do, you should have good short and long-term outcomes.

Talking about outcomes, Tarek, perhaps you could shed some light on the major outcomes that we look at in cardiac surgery, especially CABG.

Tarek Malas, MD:

That's a great question. We have some of the best outcomes in the country, and the reason is we're pressed on always looking at the details of the operation and doing a technically good operation, choosing the right patients as well. Some of the major outcomes we look at are both, first of all, survival in the hospital, and also long-term survival. That's very important for us. We follow our data and look at our patients and how well they do. Other outcomes that we look at are in the hospital, we look at the risks of strokes and risks of heart attacks. We also look at other outcomes that involve secondary outcomes. For example, do patients have risk factors with regard to things like pneumonia or being on a ventilator? We also look at things like kidney disease if patients have some kidney dysfunction after surgery.

We track a lot of these. Other things that we track include bleeding after an operation, and these are data that we track very efficiently here at the Cleveland Clinic. We always look at our outcomes to look and compare that to the national database.

Faisal Bakaeen, MD:

To have great outcomes, it really starts from the beginning, as we said, the patient work up, their heart team approach with our cardiologist optimizing the patients, selecting them appropriately and going through a technically perfect, expeditious operation. Then the outcomes will follow as anticipated, will be excellent. We have had less than one in 100 deaths, despite the high complexity of cases that we do. So, less than 1% mortality for many years now. What I mean by highly complex cases are those with severe heart failure patients on mechanical heart support or transfers from other centers because they were technically too demanding.

We also do multiple re-operations, meaning that the patients have had surgeries elsewhere and now they need another operation, a second, third, or fourth operation. Despite all those complexities, the death rate is less than 1%. If you take a healthy person who comes for elective CABG, the death rate is one in a thousand or less. It's a very, very safe operation. The risk of stroke, kidney failure, external wound infections are really, really low. They're less than 1%. Again, thanks to the multidisciplinary approach for the perfect surgery and attention to detail.

Once they have undergone the surgery, now is the recovery time. Let's talk about the recovery time for a traditional and a minimally invasive CABG. Let's start with the traditional, Tarek.

Tarek Malas, MD:

Open-heart surgery is definitely a big deal for patients. It's a big life event that definitely requires some recovery, and that's where the benefit of minimally invasive surgery is. Now, when we talk about a traditional open-heart surgery, the biggest item that requires recovery is the healing of the bone.

I tell my patients, you're going to be able to walk and push yourself from day two after surgery to walk and continue to do your activities. My hope is that your limitation will be your breastbone and not your heart. That's generally what I tell my patients.

The breastbone, because it is a fresh incision in bone, like a fracture in a bone, it takes a few months to heal. What we advise our patients is generally to avoid lifting something more than, say for example, 15 pounds for the first few months until that bone heals.

Faisal Bakaeen, MD:

Oh, you're very restrictive here. That's what many pamphlets put. I have experience in a family where an octogenarian broke a hip, they operate, stabilize the hip, and have them walk right away. As Tarek said, we have them do aerobic activity right away. That sternum, when closed appropriately with wires plus or minus plating, is pretty sturdy. The bone doesn't have to be fully healed before they can do activities of their living.

However, we want to avoid strenuous exercise and extreme lifting. You mentioned 15 pounds. I think that's a little bit too conservative. I tend to use 50 pounds. What about you, Donna?

Donna Kimmaliardjuk, MD:

Well, I'm ultra conservative. I would say for the first four to six weeks, nothing more than 10 pounds.

Faisal Bakaeen, MD:

Okay.

Donna Kimmaliardjuk, MD:

I'm very conservative.

Faisal Bakaeen, MD:

Well, this shows that there's a difference in opinion because I know that other staff at the Cleveland Clinic follow my approach, and therefore we're actually about to evaluate this in a randomized trial to give the perfect advice for our patients. But my more liberal strategy has not, in my experience, contributed to any issues, but that is something that deserves further study. Now, the minimally invasive approach, you're probably a little bit more liberal, right?

Donna Kimmaliardjuk, MD:

Oh, yes. That's really the big advantage of minimally invasive is the faster recovery. There's no difference in the quality of the bypass, that should be exactly the same, but it's really the recovery time shorter. As soon as you are feeling up to doing activities, do it. Because yes, it's minimally invasive, but it's still surgery. Those first few days, you might be a little tired, you might be a little sore. You might not feel like swinging a golf club yet or doing activities, but when you're feeling up to it in a week or two, you can.

Faisal Bakaeen, MD:

The length of stay in the hospital, many people ask, on average is five days at Cleveland Clinic. I'm sure, Tarek, you've had patients who are ready to go home day three, but some patients are a little slower, have little issues, may take a couple of extra days. But in general, would you agree that five days for a traditional approach? I've had minimally invasive patients who would leave the same or the next day, but I've kept them an extra day just in case.

Donna Kimmaliardjuk, MD:

Yeah. I do two to three days after minimally invasive.

Faisal Bakaeen, MD:

Okay, that sounds reasonable. That sounds reasonable. Now, some patients get post-operative atrial fibrillation, which is not dangerous. That can prolong the length of stay a little bit longer.

We talked about the spectrum of care from workup to surgery to post-op care. You emphasize the medications. What about secondary prevention? What do people do after they leave the hospital, and longer term, to optimize the long-term outcomes?

Donna Kimmaliardjuk, MD:

There are certain medications that you should plan to be on for life. That baby aspirin is one of our best friends that really helps with bypass grafts in certain patients, as I think a lot of the surgeons here will do too. You might go on Plavix as well for a period of time to help with the bypass grafts. I tell patients the things that you're told before surgery to be healthy and heart healthy, we're still going to say after surgery. So, making sure your blood pressure is well-controlled, so you might still need to be on blood pressure medications. Beta blocker, ideally in those early months after surgery, it keeps the heart from being stressed out because it keeps it a little slower, so doesn't have to work so hard.

Before surgery, you probably would've been talking about making sure your cholesterol is well-controlled, and triglycerides. It’s going to be the same thing after surgery. Also, these statins have been shown to help with patients and longevity of the bypass grafts as well. Secondary prevention is huge and really, the improvements we've seen in medications are what have also helped the long-term patency of some of the grafts.

Tarek Malas, MD:

Atherosclerotic disease is going to continue to progress and it's not something that you stop. What we can do is slow it down by controlling those risk factors. Say, for example, controlling diabetes, controlling blood pressure, cholesterol, things that actually progress. The coronary disease actually progresses in both the grafts, the stents and the native arteries, and that will continue to progress. What we do is by controlling the risk factors through secondary prevention, we can actually reduce the progression of the disease and improve long-term outcomes.

Faisal Bakaeen, MD:

So, we do our part, the surgeons, but you, the patients need to do your part, and we can help you do that.

Now, this has been a fascinating discussion. We covered CABG, coronary artery bypass grafting. What we didn't talk about is treatment of coronary aneurysms. It's when the vessel enlarges in size and this can cause complications in heart attacks. We didn't talk about anomalous coronaries, meaning coronaries that come off different than normal takeoff and pathway around the heart. These are topics for further discussion, but we offer specialized care for those patients because these are uncommon scenarios. You need a center that's experienced with higher-volume patient load to address those anomalies and pathologies effectively and safely.

Thank you very much for joining us. Donna and Tarek, this has been really excellent. I've actually learned something today. I hope you enjoyed this as much as I did.

Tarek Malas, MD:

Fantastic. Thank you very much.

Faisal Bakaeen, MD:

Thank you very much.

Donna Kimmaliardjuk, MD:

Yes. Thanks so much.

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