On-X LTI 15 Years of Clinical Excellence On-X LTI 15 Years of Clinical Excellence

Announcement

Announcement Module
Collapse
No announcement yet.

Coronary artery bypass with AVR

Page Title Module
Move Remove Collapse
X
Conversation Detail Module
Collapse
  • Filter
  • Time
  • Show
Clear All
new posts

  • Coronary artery bypass with AVR

    My surgeon wants to do a bypass graft on the circumflex coronory artery"while he is in there". It is not strictly necessary at this stage (30% blockage. My question is, has any ,members had CABS with their valve replacement surgery? What are the additional issues with surgery (time on pump?) and recuperation afterwards?

    Johan
    Johan
    Diagnosed with heart murmer at age of 6. AVR 1 July 2009 at age 66. Carpentier-Edwards Perimount Magna Thermafix Model 3000TFX/21mm plus 1 CABG. Christiaan Barnard Memorial Private Hospital in Cape Town, South Africa. Surgeon Dr Otto Thaning.

  • #2
    The reason most patients have a Cardiac Catheterization before Valve Surgery is to determine if there are any coronary arteries that are blocked sufficiently to warrant Bypass Grafting at the same time. The Question for you to ask (and it would be wise to get multiple opinions on this) would be "what is the prognosis for your 30% blocked artery?" If it is likely to continue to become more stenotic, then yes, you are probably better off getting it bypassed "while he is in there".

    Combining CABG (Coronary Artery Bypass Graft) with Valve Replacement is a fairly common procedure inpatients with both Valve Disease and Coronary Artery Disease. It is my (non-professional) understanding that this has little impact on the (low) complication rate. Doing Both in ONE Surgery is WAY better than coming back for a Second OHS would be Much more traumatic and elevates the risk due to having to deal with Scar Tissue when opening the chest a second time, not to mention having to go through the discomfort and lost time for a second Recovery.

    Placing a Coronary Artery Bypass Graft is a fairly simple procedure where the surgeon makes a small incision inline with the artery, inserts the graft, and sews it in place.

    'AL Capshaw'

    Comment


    • #3
      If you have the CABG you will have additional pain in your leg from where they take the graft. My son complained a lot about that pain which I am told can sometimes be worse than the OHS. 1 graft doesn't sound too bad, you certainly don't want another surgery later.

      Can they stent it if they don't do the CABG?
      Deanne
      __________________________________________
      Mom of patient - 19 yr old Brian (pictured)
      Aortic dissection, 2 emergency OHS 6/30/06 & 7/1/06, heart failure, implantation of Heartmate II LVAD, triple CABG
      3/13/07 explantation of LVAD, on-x aortic valve, dacron ascending aorta, mitral valve repair, 1 new CABG

      Comment


      • #4
        I am scheduled for a bypass along with my AVR and mitral repair, and was given pretty much the same explanation as above. Additionally, they told me that if my normal artery provides enough flow capacity after the surgery, and the bypass does not get not enough blood flow, the bypass might die off. It is a prophylactic measure, since the location of the artery is such that it can not be accessed by any other means than OHS.

        They are going to use a artery from inside my chest wall, or if for some reason this can not be used, a vein from the leg.

        Karl.
        Last edited by realkarl; June 16th, 2009, 07:41 AM. Reason: replaced 'vein' w 'artery' ..inside my chest wall
        On-X 21mm Aortic valve, Mitral Annuloplasty 24mm ring, LIMA bypass, 7/21/2009 @ age 39, Dr Mark E Hill
        St. Jude Anthem RF Biventricular pacemaker (CRT-P) for Left Bundle Branch Block, 1/11/2010

        Heart problems caused by radiation therapy @ age 15, to cure Hodgkin's lymphoma.

        Comment


        • #5
          Thanks Al, Deanne and Karl

          My scheduled surgery is now 10 days away and this is the one aspect that I still do not have clarity about. From the start I questioned the need for the CABG on the circumflex coronary artery as I remember (borne out by the reports from that time) that my cardiologist "saw" this moderately blocked artery as long as 5 years ago, when they did the first angiogram for the aortic valve. He did not do anything about it then (stenting) because he felt it was not clinically necessary. The surgeon is the one pushing for the bypass as he does not "believe" in stents. My cardiologist now tells me that it will be a difficult stent because of the shape of the artery in the vicinity of the blockage. Fortunately I managed to get CD discs of all 5 of my previous angiograms. Used my old man charm on the computer nurse in the Cath Lab!! I shall now follow Al's advice and take these discs to 2 other cardiologists to get some verdict on the stentability of the this artery if needed in future.

          During my interview with the surgon I reluctantly agreed with the CABG but pushed for the internal mammary artery in the chest to be used, mainly to avoid the leg problems as described by Deanne. I, however, received the same response as Karl from the surgeon about the graft dying off (apparently it is called stringing) if the native artery is still too open. This however only happens when the graft is also an artery such as the one from the chest. Apparently this does not happen to veins, as the one from the leg. You may want to run this past your doctors, Karl. As Karl said it is a prophylactic measure. My surgeons last remark was "we use a vein from your leg and then you will have two beautiful pathways feeding that part of your heart".

          Sounds good but I shall still go for my second and third opinions on future stenting of the artery.

          Johan
          Johan
          Diagnosed with heart murmer at age of 6. AVR 1 July 2009 at age 66. Carpentier-Edwards Perimount Magna Thermafix Model 3000TFX/21mm plus 1 CABG. Christiaan Barnard Memorial Private Hospital in Cape Town, South Africa. Surgeon Dr Otto Thaning.

          Comment


          • #6
            Johan: I will discuss the leg vein option with my surgeon and cardiologist when they have decided on their bypass recommendation. In the meantime I did however find this article, which says

            "In contrast to saphenous vein grafts, the long-term patency rate of arterial bypass conduits is very high, with 85% to 95% of grafts free of significant stenosis at 7 to 10 years.1–6 This is supposed to be because of physiological, anatomic, and hemodynamic characteristics.7 Therefore, the use of arterial conduit is now unanimously accepted as the best choice for surgical revascularization.."

            http://circ.ahajournals.org/cgi/cont..._suppl_1/II-36

            and this

            "Complete graft occlusion was significantly more common with saphenous-vein grafts (13.6%) than with radial-artery grafts (8.2%). However, an angiographic "string" sign (diffuse narrowing to <1 mm) was evident in significantly more radial-artery (7.0%) than saphenous-vein (0.9%) grafts".

            "The grafts are more likely to occlude if there is less flow in the bypassed vessel. Overall, patency was better with radial-artery grafts than with saphenous-vein grafts. The importance of the higher incidence of string signs in the radial-artery grafts is debatable"

            http://cardiology.jwatch.org/cgi/con...ull/2005/107/1

            So it appears the grafts can suffer from both occlusion and stringing if the flow of the bypassed vessel is high, and that occlusion and stringing are two different potential outcomes. This is clearly complex enough to not make any decisions based on "Google research".. but probably an indication it is best to get several professional opinions on the matter.

            I would be curious what you find out when you take your CDs to other doctors. In addition to the stentability question perhaps you can ask about the choice of saphenous-vein grafts vs radial-artery grafts.
            On-X 21mm Aortic valve, Mitral Annuloplasty 24mm ring, LIMA bypass, 7/21/2009 @ age 39, Dr Mark E Hill
            St. Jude Anthem RF Biventricular pacemaker (CRT-P) for Left Bundle Branch Block, 1/11/2010

            Heart problems caused by radiation therapy @ age 15, to cure Hodgkin's lymphoma.

            Comment


            • #7
              Karl: Most interesting! I looked at both the articles and it is now clear to me that the choice of bypass conduit is as complex as choice of valve. I only have 10 days but will now certainly get as many opinions on the matter as possible. My first choice would be no CABG during my AVR. But if it is felt that I need the bypass then I need to know that they use the best vessel for the job! Will keep posting. Thanks again for the pointers. Johan
              Johan
              Diagnosed with heart murmer at age of 6. AVR 1 July 2009 at age 66. Carpentier-Edwards Perimount Magna Thermafix Model 3000TFX/21mm plus 1 CABG. Christiaan Barnard Memorial Private Hospital in Cape Town, South Africa. Surgeon Dr Otto Thaning.

              Comment


              • #8
                Johan: I asked my cardiologist about my bypass, and he informed me that they would be using a LIMA in my case (LIMA (LITA) = 'left internal mammary (thoracic) artery'), and that they rarely, if ever, close down.

                He is a little short in his email communication, but from what I can read elsewhere, this is because they would have to detach only one end of the artery, and the other end stays in place: http://en.wikipedia.org/wiki/Coronar...bypass_surgery "Generally the best patency rates are achieved with the in-situ (the proximal end is left connected to the subclavian artery) left internal thoracic artery with the distal end being anastomosed with the coronary artery" ("patency rate" = chance of staying open.)
                I am glad I found out; it simplifies my case.
                On-X 21mm Aortic valve, Mitral Annuloplasty 24mm ring, LIMA bypass, 7/21/2009 @ age 39, Dr Mark E Hill
                St. Jude Anthem RF Biventricular pacemaker (CRT-P) for Left Bundle Branch Block, 1/11/2010

                Heart problems caused by radiation therapy @ age 15, to cure Hodgkin's lymphoma.

                Comment


                • #9
                  Karl: This is exactly as I originally envisaged my bypass to be effected. Using the LIMA, detaching only one end of the artery leaving the other end in place. My surgeon explained it all at our first meeting and I was happy. Then, at our last meeting he suddenly suggested a vein from my leg along with the story about arteries "stringing" and veins being better. I am not so convinced and am very grateful to you for also researching this matter. I think you and your surgeon are on the right path and you can now have some peace of mind.

                  I have a sneaky suspicion that both my cardiologist and surgeon know that my native artery is too widely open at this stage and they are now jumping around to find the best solution for this bypass. My feeling is not to bypass now with the AVR and to go for stenting later, when and if needed. I have arranged to leave my angiogram CD's with another cardiologist today. Will hopefully have some response from him soon.

                  If we all agree that the bypass is necessary with the AVR then I will push for your surgeon's LIMA solution.

                  Johan
                  Johan
                  Diagnosed with heart murmer at age of 6. AVR 1 July 2009 at age 66. Carpentier-Edwards Perimount Magna Thermafix Model 3000TFX/21mm plus 1 CABG. Christiaan Barnard Memorial Private Hospital in Cape Town, South Africa. Surgeon Dr Otto Thaning.

                  Comment


                  • #10
                    This has been a Very Interesting Thread to me.

                    Thanks for bringing up the subject and thanks Karl for your reference material and links.

                    I can certainly understand being reluctant to Bypassing an Artery with mostly unrestricted flow yet available.

                    'AL Capshaw'

                    Comment


                    • #11
                      If they have to crack your chest and be on the pump you might as well get a complete overhaul while your at it. That was my procedure...(aside from my body serving as a live victim for training purposes)...I guess it was worth it...

                      My 2 cents,
                      Riding the INR bubble

                      Comment


                      • #12
                        Agree with Roger. Just don't want them to mess around with a functional vessel...have taken all my heart documentation to new cardiologist...will hopefully have his opinion soon.
                        Johan
                        Diagnosed with heart murmer at age of 6. AVR 1 July 2009 at age 66. Carpentier-Edwards Perimount Magna Thermafix Model 3000TFX/21mm plus 1 CABG. Christiaan Barnard Memorial Private Hospital in Cape Town, South Africa. Surgeon Dr Otto Thaning.

                        Comment


                        • #13
                          realkarl brings up very good points. They are VERY worried about my son's leg vein bypasses and are assuming that he will have to have another OHS just because of the bypasses. They told me that they could not use the mammary graft because his surgeries were emergencies and/or complex and there just wasn't time left to use a mammary graft.
                          Deanne
                          __________________________________________
                          Mom of patient - 19 yr old Brian (pictured)
                          Aortic dissection, 2 emergency OHS 6/30/06 & 7/1/06, heart failure, implantation of Heartmate II LVAD, triple CABG
                          3/13/07 explantation of LVAD, on-x aortic valve, dacron ascending aorta, mitral valve repair, 1 new CABG

                          Comment


                          • #14
                            Karl and others
                            I have now had a second opinion from another cardiologist and surgeon. They have now looked at my cath lab CD's for the last 5 years and their professional opinion is that the coronary artery, scheduled for bypass grafting by my first set of doctors, is still so open that any grafted artery or vein will fail because of competitive flow in the native artery. To them it makes no sense to complicate my AVR surgery with CABG. Another interesting point they make is that my change in lifestyle, medication, supplements and exercise, since my heart attack in 2004, have now virtually stopped the progression of plaque formation in my coronary arteries. I wonder why my own cardiologist has not picked up on this, too busy to go back into the records, I presume. The new surgeon does mini-stenotomies if the surgery involves only AVR. My surgeon that I am booked with does not do mini's. I now have a huge problem switching horses 1 week before my scheduled surgery on 1 July!! Johan
                            Johan
                            Diagnosed with heart murmer at age of 6. AVR 1 July 2009 at age 66. Carpentier-Edwards Perimount Magna Thermafix Model 3000TFX/21mm plus 1 CABG. Christiaan Barnard Memorial Private Hospital in Cape Town, South Africa. Surgeon Dr Otto Thaning.

                            Comment

                            Working...
                            X