Coronary Artery Disease

Getting the Therapy

Getting Treated for Coronary Artery Disease

Each year, people worldwide receive stents or bypass surgery. Stents are minimally invasive, and may only require one night in the hospital. A beating heart bypass is major surgery that employs a device to stabilise a small area of your beating heart.

You can do a lot to control cardiovascular disease by taking medications, changing your diet, and making other lifestyle changes. But sometimes, those changes aren't enough to reduce the effects of clogged arteries. When that is the case, or if you have a heart attack or other symptoms of coronary artery disease, your doctor may suggest that you see a cardiologist.

Factors Your Doctor May Consider

To determine what treatment is right for you, your cardiologist will take a number of factors into consideration, including your age, your cardiovascular condition, the condition of your coronary arteries, your overall medical condition, and your health history. After a series of tests, your cardiologist may suggest angioplasty, stenting, or coronary artery bypass surgery (CABG).
More: Stenting
More: Bypass surgery

Your Healthcare Team

If you are a candidate for coronary artery disease treatment, your cardiology team will be involved at every stage of the procedure. Depending on the therapy, the team may consist of cardiologists, cardiac surgeons, radiologists, anaesthetists, nurse practitioners, and other specialists as needed.
More: Stenting
More: Bypass surgery

Surgery: What to Expect

Unless you are faced with a medical emergency, you will have time to learn about your surgery, what to expect, and how to prepare. Take an active role in learning about the procedure, so that when your doctor explains the surgery to you, you will already be somewhat familiar with the procedure.
More: Stenting
More: Bypass surgery

Next: Factors Your Doctor May Consider

Balloon Angioplasty and Stenting

Factors Your Doctor May Consider – Stenting

Stenting is now a standard procedure for the treatment of coronary artery disease.

Here are some of the factors that could help your doctor determine whether you're a candidate for stenting:

Your overall health
The size of the vessel and number of coronary arteries involved
The location of the blocked coronary artery
How easily the blockage can be reached by angioplasty
Your recent coronary health history – including heart attacks

Under certain circumstances, if your heart is weak or if you have other diseases that affect the health of your heart, such as diabetes or other conditions, coronary artery bypass surgery (CABG) may be your best option. Your doctor will evaluate your condition and recommend the best option for your specific condition.

Next: Your Healthcare Team

Your Healthcare Team – Stenting

Once you and your doctor have decided on the treatment best suited to your condition, you will become involved with a team of specialists that are responsible for the procedure from beginning to end.

General Cardiologist

The cardiologist is a doctor who specialises in taking care of the heart and blood vessels. This specialist examines patients to identify symptoms of heart disease using a variety of tests. If the heart problem is related to coronary artery disease, the cardiologist may recommend lifestyle changes, medications, and treatments such as coronary artery bypass grafting (CABG), angioplasty, and/or stenting.

Interventional Cardiologist

Interventional cardiologists are cardiologists who have completed years of additional training in interventional procedures – catheterisation, angioplasty, stent placement, and the use of other devices to remove plaque from the inside of the arteries.

Nurse

Nurses are a critical part of your care team. They assist the interventional cardiologist, and it is their responsibility to manage your care and comfort at each stage of the procedure – from preparation to recovery.

Radiographer

A radiographer is a person who has been trained in the use of x-ray equipment and to assist the doctor and nurse with interventional cardiology procedures in the catheterisation lab, or "cath lab," where the stenting procedure is performed.

Next: The Procedure: What to Expect

The Procedure: What to Expect – Getting a Stent

Your stent procedure will be done in a specially equipped room in the hospital called a cardiac catheterisation lab. The procedure will be done by an interventional cardiologist, a doctor who specialises in angioplasty and stenting. Your care team will also include nurses and catheterisation lab technicians.

Before the Procedure

Your doctor will decide which site on your body would be the best place to access one of your arteries – your groin area, wrist or arm. The selected area will be cleaned, shaved and numbed with a local anaesthetic. If you know in advance that you will be receiving a coronary stent, your doctor will ask you to follow certain instructions to prepare for your stent procedure.

Your doctor needs to know what other medications you are taking. In most cases, you should take any medications that you usually take, especially blood pressure medications. Check with your doctor about which ones to take and which ones not to take.

Also, be sure to tell your doctor if you:

Cannot take aspirin
Have any allergies
Have a history of bleeding problems
Are or might be pregnant, or are breastfeeding
Are planning to have any other surgeries or dental work soon

Your doctor may have you take aspirin and other medications for several days before you get your stent. These medications will help prevent blood clots from forming during the stent procedure.

You may be asked not to eat or drink anything for a period of time before your procedure. If your doctor wants you to take your regular medications, you may take them with a little water.

During the Procedure

Stents are inserted into an artery through a catheter, similar to an angioplasty procedure. You will lay flat on your back on a table during the procedure. Devices will monitor your heart rate and blood pressure.

Your stent procedure will begin with an angiography test to determine the number and exact location of blockages.

After your doctor has determined which, if any, blockages need treatment, he or she will implant the stent:

With x-ray guidance, your doctor will advance a thin wire through the catheter to the treatment site in the coronary artery to penetrate the blockage and provide support for the stent delivery system.
A tiny deflated balloon will be advanced to the blockage along the wire that is already in place. Once the balloon is inside the blockage, the balloon will be inflated. Inflating the balloon squeezes the plaque against the wall of the coronary artery, widening the artery opening.
Next, another tiny deflated balloon with a stent mounted on it will be advanced to the blockage. Once the stent is inside the blockage, the balloon will be inflated. Inflating the balloon expands the stent that surrounds it. The stent locks in place against the artery wall, forming a scaffold to help keep the artery open. (It is common for patients to feel some mild discomfort when the balloon is inflated because the artery is being stretched. Your discomfort should disappear as the balloon is deflated.)
After the stent is fully expanded, additional x-ray pictures will be taken to determine if the stent is fully open and how much blood flow has improved. Your doctor may decide to inflate the balloon additional times to be certain the stent is firmly pressed against the vessel wall.
When your doctor is satisfied that the stent is fully open and adequate blood flow has been restored, the balloon catheter, guidewire, and guide catheter will be removed.

After the Procedure

You should plan to stay overnight at the hospital. You will need to make arrangements to have someone drive you home when you are ready to leave. Be sure to follow your doctor's instructions about taking your medications.

Next: Factors Your Doctor May Consider

Beating Heart Bypass Surgery

Factors Your Doctor May Consider – Beating Heart Bypass Surgery

You can do a lot to control cardiovascular disease. Follow any advice from your doctor such as taking medication, changing your diet, or exercising regularly. Making these and other lifestyle changes can help. Sometimes, these changes aren’t enough to reduce the effects of clogged arteries.

When that is the case, or if you have had a heart attack or other symptoms of coronary artery disease, your doctor may send you to a cardiologist.

A cardiologist specialises in diseases of the heart. Your cardiologist will test your cardiovascular system. After a few tests, your cardiologist may recommend coronary artery bypass surgery (CABG).

Testing

Next, you will undergo tests to find out which arteries are clogged. These tests can show how much your arteries are clogged and whether your heart is damaged.

Surgery

Once your condition is known, your surgeon will decide whether to operate on pump or off pump. On-pump means you will be placed on a heart-lung machine during surgery. Your heart will be stopped and the heart-lung machine will take over your breathing and blood pumping function.

Off-pump means your heart will continue to beat during surgery. The area where the surgeon is working will be immobilised by a tissue stabilisation system.

What Makes You a Candidate for Beating Heart Surgery?

Your doctor will evaluate your condition and recommend the best option for you.

Here are some of the criteria that will be considered when your doctor decides if you are a candidate for beating heart bypass surgery:

Your overall health
Your age
Your gender
Amount of heavy aortic calcification – buildup of calcium deposits on the arteries
Prior stroke
Weakened heart muscle
Carotid artery stenosis – a narrowing of the carotid artery

Next: Your Healthcare Team

Your Healthcare Team – Beating Heart Bypass Surgery

Once you and your doctor have decided on the treatment best suited to your condition, you will become involved with a team of specialists that are responsible for the procedure from beginning to end. Based on the results of your tests, your cardiologist will help you decide what treatment is right for you. Others who may be involved in your treatment decision are a cardiac surgeon, an electrophysiologist, an anaesthetist, a nurse, and other specialists as required.

Cardiologist

In situations where drug therapy and/or angioplasty/stenting are not effective or appropriate treatments, the cardiologist may refer the patient to a cardiac surgeon.

Cardiac Surgeon

Cardiac surgeons are doctors specially trained in the surgical treatment of heart disease. Surgeons go through many years of training to learn to perform operations on the heart and blood vessels of the body.

Electrophysiologist

Electrophysiologists are cardiologists who have received additional specialised training in the diagnosis and treatment of heart rhythm disorders. This specialised training includes performing (electrophysiologic) testing, a procedure that diagnoses potentially serious arrhythmias. The electrophysiologist leads a team of specially trained health care professionals, technicians, and nurses who assist the doctor during the procedures.

Anaesthetists

Anaesthetists are doctors who have specialised training in anaesthesia. Their focus is on pain management and making sure that you are safe. They will be involved in all stages of your surgery – before, during, and after the procedure.

Nurse Anaesthetist

The certified registered nurse anaesthetist (CRNA) assists and supports the anaesthetist. They are responsible for controlling the anaesthesia during the operation and helping to ensure your safety following the procedure.

Radiologist

The radiologist is a medical doctor who works closely with the cardiologist and cardiac surgeon to provide images of the coronary arteries that help the surgeon perform the treatment procedure.

Perfusionist

Some heart bypass operations require that the heart be stopped. The perfusionist is in charge of the heart/lung machine that keeps blood flowing through your body while your heart is at rest. When your surgery is complete, the perfusionist and the surgeon work together to restart your heart.

Theatre Nurse

Nurses are a critical part of the surgical team. It is their responsibility to manage your care and comfort at each stage of the procedure – from preparation to recovery. They also assist the surgeon during the operation.

Nutritionist

Proper nutrition is essential before surgery and during recovery. Nutritionists are highly trained experts who instruct nurses responsible for your care on how best to meet your nutritional needs and speed your recovery.

Physiotherapist

Physiotherapists work with you and your doctor to help you recover physically from the surgery. They advise you on what types of physical activity you should or should not do and how best to regain your strength and mobility after surgery.

Social Worker

Many hospitals provide social workers who are available to discuss any needs you may have after surgery to help you make the transition back to your daily routine.

Next: Surgery: What to Expect

Surgery: What to Expect – Beating Heart Bypass

Beating heart coronary artery bypass surgery is used to treat tens of thousands of people worldwide every year.

During beating heart bypass surgery, your heart continues to beat. You will not be put on a heart-lung machine. The part of your heart the surgeon works on is held still by a tissue stabiliser.

Before the Procedure

Today’s beating heart surgery candidates can take care of most of the preparation for surgery on an outpatient basis.

You will need to get chest x-rays, blood tests, an electrocardiogram (ECG), and a coronary angiogram. An ECG detects and locates the source of the heart problem. An angiogram is a type of x-ray that uses dye to make the arteries that feed your heart visible. These tests give your surgeon a good idea of your overall health and where the blockages are located.

You will also meet with your doctor, nurses and other members of your healthcare team. They will provide information and education about your upcoming surgery. This is a great time to ask questions and discuss any concerns you have.

During the Procedure

Off-pump heart bypass surgery usually lasts from 3 to 6 hours¹ – depending on how many arteries are involved. You will get a general anaesthetic and a breathing tube. Your heart will continue to beat during surgery.

First, your surgeon makes an incision down your chest. Your breastbone is divided to allow access to your heart. Next, the surgeon harvests veins or arteries from somewhere else in your body to create grafts. For MICS (minimally invasive) CABG procedures, a small incision is made between your ribs.

The surgeon attaches one end of the graft above the blockage and the other end below the blockage. To attach the grafts while the heart is beating, the surgeon uses a stabilisation device to keep a small section of the heart still. Typically, a heart positioner is also used. Once the grafts are sewn into place, the chest incision is closed.

After the Procedure

While procedures may vary from hospital to hospital, generally after your surgery, you will be monitored closely in the intensive care unit (ICU). Once you have been stabilised and are alert, you will be transferred to a step-down unit where you will stay until discharged. Beating heart CABG and MICS CABG patients commonly have shorter ICU stays than conventional CABG patients.^2,3

Your nurse, doctor and cardiac rehab staff will work with you and your family to answer any questions that you have. They will instruct you on topics such as incision care, diet, medications, activity, and other questions that might arise.

Your healthcare team will determine when you are ready to go home. Both beating heart CABG and MICS CABG approaches can potentially lead to shorter hospital stays compared to conventional bypass.² Once you are discharged, they will give you instructions on what to expect as you continue your recovery at home.

Next: Life After Treatment for CAD

References

Heart Center, The North American Heart Risk Study. Available at: www.qualityoflife.org

Puskas J Cheng D, Knight J, Angelini G, DeCannier A, Dullum M, Martin J, Ochi M, Patel N, Sim E, Trehan N, Zamvar V. Off-pump versus conventional coronary artery bypass grafting; a meta-analysis and consensus statement from the 2005 ISMICS Consensus Conference. Innovations. 2005; 1;3-27.

Subramanian VA, Patel NU, Patel NC, Loulmet DF. Robotic assisted multivessel MidCAB with port-access stabilization and cardiac positioning: paving way for outpatient in CABG? Abstract submitted at the Society of Thoracic Surgeons meeting. San Antonio, TX January 25-28, 2004.

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