What You Need to Know About Coronary Artery Bypass Grafting

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. These podcasts will help you learn more about your heart, thoracic and vascular systems, ways to stay healthy, and information about diseases and treatment options. Enjoy.

Dr. Faisal Bakaeen:

Hello, I'm Faisal Bakaeen. I'm Professor of Cardiac Surgery at the Cleveland Clinic and the director of the Coronary Center. I'm joined here today by Dr. Aaron Weiss, who I had joined our faculty three years ago, and he has special interests in coronary artery bypass surgery, and hopefully today will share some insights with you and we'll use Dr. Aaron Weiss’ energy, enthusiasm, and passion towards that procedure to hopefully discuss things that could be of value to you if you have coronary disease or if you have loved ones with that disease. Aaron, welcome.

Dr. Aaron Weiss:

Thank you, Faisal. It's wonderful to be here and it's been wonderful working with you for the past three years on high risk bypass surgery. It's truly been an honor to carry on the legacy here at the Cleveland Clinic with coronary artery disease.

Dr. Faisal Bakaeen:

Well, talking about legacy, coronary artery bypass surgery started really here at the Clinic. Dr. Favaloro, back in the late sixties popularized this procedure and it became one of the most common surgical procedures that is performed. There's debate on who actually did the first procedure ever, but what is not in debate, what is confirmed, what is unimpeachable is that Dr. Favaloro and the team here at the Cleveland Clinic were the ones that made it an effective, safe procedure that was popularized and became the standard of care for treating many patients with coronary artery disease. This procedure has evolved over the years. Perhaps we could start by explaining to our audience a little bit about coronary artery disease and how it's treated.

Dr. Aaron Weiss:

Sure. Well, coronary artery disease is blockages within the arteries that feed blood flow to your heart. There's three main ways of treating this. The first one is medical therapy, and that's the mainstay of treatment throughout the other two options, which we'll discuss right now. The second option is stents, and this is a great option for isolated, single vessel disease or sometimes more complex multi vessel disease or patients who are not candidates for open surgery. And the last option is coronary artery bypass grafting (CABG), which has been popularized here at the Cleveland Clinic. And we stand on the shoulders of the giants that came before us that allowed us to do such a great job and continue to have such excellent outcomes with this procedure.

Dr. Faisal Bakaeen:

Yes, so, the way I look at the coronary artery bypass surgery here at the Clinic is it's a boutique practice even though many people think of coronary artery bypass surgery as a generic procedure, but in fact it's quite nuanced because not every CABG is the same. Here at the clinic, we pioneered the use of multi arterial grafting, specifically the use of a second internal thoracic artery. We have two of them. And the gold standard is to use the left internal thoracic artery, or some people call it mammary artery. At the Clinic, Dr. Lytle argued or reasoned that using two of them is better than using one. And this data was validated here and proven that in those patients who received multi-tier grafting, specifically two internal thoracic arteries have better long term outcomes.

Dr. Faisal Bakaeen:

There's emerging data that using other arterial grafts including the radial artery may be beneficial too. So what you use to do the bypass as you know makes a difference specifically in the long term outcomes. What aspects of your practice in terms of approaches, in terms of complexity, would you want to highlight to our audience?

Dr. Aaron Weiss:

Sure. So just to elaborate a little bit more about the multi arterial grafting approach, and that tends to be our default here at the clinic where we want to utilize a second arterial graft as often as possible. Now, there are some cases where it's just not a good idea by going by the evidence that's available. But for the vast majority of patients, we can assess them for either using a radial artery contract or as Dr. Bakaeen said, a second internal thoracic artery. And high rates of utilization of this have been associated with increased durability and survival in the long haul. And so when you're being evaluated for bypass surgery or as the surgeon, you're evaluating a patient, what you really want to do is do safe and effective surgery early, but really maximize that benefit in the long term. And that way patients can avoid having repeat procedures or repeat hospitalizations, future MIs and live longer. And also more importantly, getting back to having a normal day to day life and a quality of life that's consistent with what they enjoy.

Dr. Faisal Bakaeen:

Yeah, you're right, because the immediate outcomes of CABG have been excellent. In fact, at the Cleveland Clinic, as you know, the risk of death, despite the complexity of many of the cases we do, as many of the cases that we get are turndowns from other cardiac centers. And despite of the complexity, despite of multiple reoperations involved in many of those cases, the risk of death is exceedingly low, way less than 1% for many, many years, which is really remarkable at how safe this operation is. But the patients want to be reassured that what they have is durable. Are they going to see their grandkids graduate? Are they going to see their great grandkids?

Dr. Faisal Bakaeen:

And that is where this operation that you perform and you do it right and you choose your conduits perfectly at the first operation, when you select the patients and the appropriate conduits for those patients, then you assure that long term outcome. And that's what differentiates a center of excellence from an average center. What also differentiates center of excellence from other centers is the complexity of the procedures and the diversity of approaches. Perhaps you could maybe comment on, on pump off pump, high risk CABG and other aspects of those revascularization strategies that I've mentioned?

Dr. Aaron Weiss:

Sure. So if you need a bypass surgery, I think it's important to have it done at a center that offers the full gamut and wide spectrum of options when it comes to bypass surgery. So you want to go to a place that can optimize the approach. And what do I mean by that? Well, is this patient eligible for maybe a minimally invasive incision, which we would try to do in select cases, however, not at the compromise of quality for the overall heart surgery. So our standard approach is through a full sternotomy. Next, do we need to do the case on pump or off pump? And having the skill set to do both is very important. And although the evidence is swayed in favor of doing on pump, and that's our default strategy, there are cases that benefit greatly from doing the case off pump.

Dr. Aaron Weiss:

And having that ability to pivot and do the right thing for the patient to make the operation safe is incredibly important. The other important aspect of a bypass surgery here at the clinic is our use of temporary mechanical circulatory support to help in high risk CABG patients. And so what do I mean by high risk? Well, often patients are turned down at other hospitals due to having too low of an ejection fraction or too weak of a heart. When those patients then get transferred over here, we have certain strategies that we employ that allow us to be able to do these cases not only with great safety, but also that help in the long haul maximizing that durable benefit. And so having the skill set of me as a heart failure surgeon and also a bypass surgeon, if patients need that additional help in the immediate perioperative period and they need an Impella or a balloon pump or ECMO or anything else that may allow them to have a better outcome, we're able to do that right then and there.

Dr. Faisal Bakaeen:

Yeah, you mentioned the word Impella. Impella is a temporary mechanical support whereby we could use a device that's placed in the axillary right here by the shoulder that could support the heart during the high risk operation and allows the heart to recover gently as it gets stronger after the bypass surgery. That minimizes the risk of the surgery, makes it safer and improve the outcomes. So, back to the boutique practice of using the correct grafts, using more arterial grafts when possible, using a on versus off pump technique, avoiding the heart-lung machine when it's appropriate to do so, you got to have that in your skill set. And doing high risk operations with a weak heart or reoperations, a fair amount of our practice is reoperations whereby they've had surgery before and the grafts specifically the veins have become diseased.

Dr. Faisal Bakaeen:

And we have the largest redo coronary artery bypass surgery center in the world with, again, one of the best outcomes. So now that we've talked about the traditional approaches, you mentioned a little bit about the minimally invasive approaches because many patients wonder, is coronary artery bypass surgery through the midline, through the sternum, a sentence of being confined at home for two months and doing nothing. How do you respond to this perhaps misinformation or myth?

Dr. Aaron Weiss:

Well, sure, no, it is a common question being asked when you see patients in the outpatient clinic, and which you want to reassure patients, is that this is actually a very, not only a safe operation, but you get back up on your feet in a very short period of time. By the time you're ready for discharge, they post update four or five after the traditional sternotomy. You're doing everything for yourself except no heavy lifting. And so even then that gets graded up within the first six weeks or so and you're back running around doing everything you want to do in a very short time period after that. And not only are you doing everything you want to do, but the symptoms that brought you in for that surgery to begin with will be improved and you'll be enjoying that life that you want to live.

Dr. Faisal Bakaeen:

I agree with you. I think our emphasis has shifted over the years. We are strong believers now in fast tracking patients and moving them along because actually do better when we adopt this strategy. And it turns out that even when we use a sternotomy approach, if you do a secure closure with wires plus or minus additional adjuncts, then those patients are able to do activities of daily living pretty much right away. It is strenuous activity, heavy lifting, golfing that we tell them to take it easy upon themselves in that regard until the bone heals completely. And that takes a while. But they don't have to stay at home, they don't have to stay in their couches until that happens. They can do pretty much their activities of daily living without too much of being hard on themselves in terms of recovery. But if we were to do a minimally invasive approach, and we do that selectively, we do it in patients who typically have disease in the most important vessel of the heart, and that's the left anterior descending artery.

Dr. Faisal Bakaeen:

And if the disease is isolated to that specific vessel, then we have the capability to safely and effectively do a small incision between the ribs on the left side and to harvest that internal thoracic or internal mammary artery and sew it to that important vessel with the beating heart, without using the heart-lung machine. And we've had tremendous success with this operation with quality control in and out of the operating room. Because the last thing that you want is to do a minimally invasive approach, but to compromise the quality of the procedure. So we verify that the graft is open, at the time of surgery, so there's absolutely no doubt about the product, about the surgical outcome that you have there and then. And we also do a CT angiogram, an uninvasive way to demonstrate that that graft is open. And we have moved towards doing more and more less invasive approaches as appropriate, but quality is untouchable. I think we all agree on that.

Dr. Aaron Weiss:

That's a very important point. And when I speak to patients about less invasive options, if in fact the patient's a candidate, I always give the qualifier of if this surgery is done and it's not safe or the quality is compromised in any way, then we go the traditional full sternotomy route. There's just never a reason to compromise a patient's future for cosmesis. And so what we want to do is make sure that, like you said, is if we're going to do these less invasive approaches, nothing can suffer in terms of quality and safety. And using intra-operative assessment of graft flow is one of the ways that we make sure that a LIMA to an LAD is widely patent and is going to support that patient for the rest of their life.

Dr. Faisal Bakaeen:

And the Clinic, we adopt technologies very thoughtfully. We are at the cutting edge. In fact, robotic surgeries thrives here at the Clinic, but we use it selectively. We use it appropriately to the benefit of our patients. Now coronary artery bypass surgery, we keep talking about it as a common operation. Not only is there an isolated procedure, but many patients come in with valve disease, with aneurysms, with rhythm problems such as atrial fibrillation when they present for bypass surgery. What would you tell the audience about the importance of having the procedure performed at the center of excellence in all aspects of heart surgery, not just coronary artery bypass surgery?

Dr. Aaron Weiss:

Well, I think what's greatly important, especially here at the Clinic, is that you have expertise across the wide spectrum of pathology of cardiac surgery. And with that expertise comes a lot of volume and a lot of patients that have multi components of their surgery that are needed. And what we've shown time and time again, is that incomplete treatment of cardiac disease at the time of surgery harms patients. Leaving disease behind is something that you don't want to do. Now sometimes due to certain risk factors or other patient issues, we do have to incompletely treat patients. But our default here at the clinic is to fully treat all valve disease, arrhythmia disease, aortic disease at the same time that we do our bypass surgery. And having that aggressive mindset helps patients both in terms of needing future interventions on their heart.

Dr. Faisal Bakaeen:

It's easier to get it right the first time. It's easier to treat things comprehensively from the get go. That's our philosophy and we tend to do it well. And there's a reason to celebrate that. Not only do our patients benefit from that, but also there's a great sense of gratification on behalf of the surgeon that you've achieved a complete and comprehensive operation. And the patient really received all the attention, all the detail oriented treatment that they hoped for. I perhaps would like to pause a little bit and talking about the outcomes. The Cleveland Clinic has been recognized for excellence in outcomes over the years. There’s various metrics that are used. Perhaps you could mention a little bit about the recognitions that we've received in the arena of coronary bypass surgery and beyond.

Dr. Aaron Weiss:

Sure. So I'll start with the overall. Recently as you know we were just named the number one cardiology and cardiac surgery center in the country for the 28th year in a row. I think that's a heck of an accomplishment. But really what that comes from is our dedication to patient care on a day to day basis that then gets translated into those kinds of awards and titles. If we're not there every day for a patient doing the best thing we can do to help them, we're not going to achieve that title every single year. Speaking specifically about coronary artery disease, we've been a three star SDS program for CABG for as long as I can remember.

Dr. Faisal Bakaeen:

And that's three out of three. There's no five stars. So three is the highest, just to clarify?

Dr. Aaron Weiss:

And it's one of these things where CABG is the-

Dr. Faisal Bakaeen:

Bread and butter?

Dr. Aaron Weiss:

So CABG is thought of as the bread and butter operation in cardiac surgery. But we take pride in CABG and pushing the envelope of that while maintaining those excellent outcomes that achieved us the three stars and the number one ranking across the country. Bypass surgery is still the cornerstone of cardiac surgery. And although we are branching out and doing different things and the field is evolving, coronary artery bypass graft isn't going anywhere. And in fact, it's still the default treatment for stable multi vessel coronary artery disease.

Dr. Faisal Bakaeen:

I agree. I have coronary artery disease in my family and my grandfather, my father and two of my uncles had CABG, coronary artery bypass grafting. I might have it one day. So what advice can you give me and our audience with regards to treating the coronary artery disease?

Dr. Aaron Weiss:

Sure. As a patient, when you hear that you may need heart surgery-

Dr. Faisal Bakaeen:

Can I bring them to the Clinic?

Dr. Aaron Weiss:

I'm sorry?

Dr. Faisal Bakaeen:

Can I bring my family to the Clinic?

Dr. Aaron Weiss:

Of course you can.

Dr. Faisal Bakaeen:

I'll be honored if you were the treating doctor, of course especially with my family.

Dr. Aaron Weiss:

I would be the same with you. So as a patient, it's never easy to hear that you're going to need open heart surgery. It's our job as providers to make sure that your anxiety when it comes to this surgery is lessened as much as possible. And we're going to be there for you from the time that we first see you to the time you leave the hospital, and even beyond that. We're going to set you up with a good game plan once you leave here to be able to maximize the benefit and extend the durability of this surgery too. Having surgery at a center that has the wide spectrum of treatment options should be your priority as a patient. In that way patients can have their approach tailored specifically to them. And I think that's one of the things that we really offer here at the Clinic.

Dr. Faisal Bakaeen:

I think in summary, I would say that you want to pick up a high volume center, a highly skilled center with excellent outcomes that are proven over the years, and also a center that is focused on patient care. Patients always come first. Because when you are the receiving end, you are the focus of everything that we do, and we take pride in that. And I think we should leave our audience with a positive message that coronary artery bypass surgery is a state of the art procedure at the Clinic. The outcomes are excellent, and we are here to help answer any questions you may have. So feel free to reach out to me personally, or Dr. Weiss or our resource center. I think we'll leave you some information at the end of this presentation. Thank you very much.

Dr. Aaron Weiss:

Thank you.

Dr. Faisal Bakaeen:

Thank you, Dr. Weiss.

Dr. Aaron Weiss:

Thank you Dr. Bakaeen.

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