Expert: danil hammoudi.md Date: 5/12/2003 Subject: On or off-the-pump? Surgery this Wednesday.
Question Hi Dr. Hammoudi,
I am writing out of concern for my father's on-the-pump triple bypass scheduled for this coming Wednesday. He has 80% blockage and obviously needs the surgery, however I am doubtful of the physician's choice of procedure.
My father has a history of strokes--two transient ischemic attacks within the past two years or so, as well as history of a major heart attack. I've read and researched all I could, and cannot help but to believe that the surgery can and should be performed without the assistance of the heart-lung machine unless absolutely critical.
I've taken into consideration that perhaps the surgery may take longer, and I understand that is dangerous due to remaining "under" for extended time periods. However, I have read of doctors who perform 60-90% of their bypass surgery off-pump, including triple and quadruple. I only hope that their is something that I am overlooking.
I've attempted to contact his doctor, but he has yet to return my calls due to over-booking. My family doubts my concerns, and my father doesn't even know about the options available. Personally, I simply cannot understand why the physician would elect to perform the surgery on-the-pump, unless he is A.) not trained to perform that procedure, or B.) the hospital pushes for utilization of the heart-lung machine to drive up operating expenses.
What is your opinion on the matter? Should I tell my father of my concerns or should I keep quiet so that he can go into the surgery with a good attitude? Should I attempt to have this surgery cancelled and find another doctor?
Thanks for any advice or help,
Daniel Wyatt
danielawyatt@hotmail.com
Answer I totally understand you concern
As you might understand it is hard for me to tell you if the indication is there and where is the stenosis on his heart.
I believe that the indication of this surgeon is based on the extention of the damages and on the past medical history risk that your father went through as stroke.
he is trying to avoid any clot [although the machin give a risk and other complication low but exist] formation by filtration of his blood by this procedure and be doing a by pass without the stress of any bleeding.
but I totally agree with you that the surgeon can do a beating bypass surgery [if the indication are there] or this doc is more traditional in his methods and wait to have more conccurent statistic before starting the beat bypass surgery.
for his experience ask how many did he do and you will have an idea [ask the hospital admnistration for this]
Known most commonly as "off-pump" or "beating heart" bypass surgery, this procedure may also be referred to as OPCAB (an acronym for "Off-Pump Coronary Artery Bypass).
The procedure eliminates the use of the heart-lung machine (or "pump") during coronary artery bypass (CABG) surgery. In other words, the surgery is performed on a beating heart. The surgeon enters the chest cavity through the sternum (the chest), similar to traditional bypass surgery.
With this approach, surgeons can perform multiple bypass grafts on all areas of the heart, including the backside (posterior), at the same time. What this means is, the surgeon can perform a triple (three bypass grafts), quadruple (four bypass grafts) or more through a middle of the chest incision – all off-pump!
this is some info regarding the beating bypass which I think you need to discuss it with your father and his doc
Without a heart-lung machine: A beating heart surgery in progress
A series of tests, including an angiography, found that he was hypertense. He had coronary artery disease with features of acute coronary syndrome. Reluctant to perform a bypass at his age, the cardiac surgeon put him on medication.
"One day, however, the pain grew acute to a point of collapse," recalls Raman, "and before I knew it they were talking about surgery being the only option." In a 90-minute operation, Dr Reddy undid the damage of a triple vessel block. Thousands of Indians undergo bypass surgery every year, but what made Raman's case noteworthy is that the heart was kept beating throughout the procedure sparing him the ordeal of a heart-lung machine.
Called beating heart surgery or 'off-pump' bypass surgery, the technique reduces the trauma of a conventional bypass. New precision instruments permit surgeons to stabilise a small area of the heart and place a bypass graft, while the rest of the heart continues to beat normally. Patients spend fewer hours on a ventilator and fewer days in the intensive care unit.
Raman's wife, Rajammal, remembers him being wheeled into the operating theatre: "We were not scared because the doctor had explained to us what the surgery was all about." Ten days later, Raman was back on his feet and after adequate recouping, he resumed his morning walks.
'I am an advocate of the off-pump surgery': Dr D. Janardhana Reddy
Pioneered in 1965 by Russian cardiac surgeon Vassily Ivanovich Kolessov, beating heart surgery was considered too radical and had few takers then. It was revived in the 90s and over the years the surgery has proved to be as durable as conventional bypass. The Health Scout News reported a few months ago that nearly one-quarter of all bypass in the US are off-pump.
Dr Reddy performs most bypass surgeries without a heart-lung machine; he uses the machine only under special circumstances. "Before 1997, I was doing all my cases on cardio pulmonary bypass," he says. "The turnaround came in the last three years and we have completed 1,000 beating heart surgeries so far at Vijaya Heart Foundation." Patients feel reassured to know that the heart will continue beating through the surgery.
Conventional bypass surgery involves flooding the heart with cold fluids rich in potassium to arrest muscle contractions. The patient's blood is then rerouted into a heart-lung machine which functions as the patient's heart and lungs. There, it is forced over membranes of porous plastic, allowing oxygen to percolate. The blood is cooled to about 82 degrees F, and then pumped back into the body. As a result, body temperature drops and slows down metabolism and decreases the demand for oxygen. After surgery, the body is rewarmed.
The procedure creates an alternative pathway around the clog for the blood to deliver oxygen to the heart muscle. For the grafts, portions of an artery or vein from the patient's body is used. "Most commonly used vessels include the internal mammary arteries, which are inside the chest wall, or the greater saphenous veins from the leg," says Dr Paul Ponraj, senior consultant surgeon, Vijaya Heart Foundation. "They are termed 'spares' and their removal does not affect blood flow. The radial artery in the arm may also be used for a graft."
Although the success rate of bypass surgery is 95 per cent, exceptions to the rule do exist. According to a research conducted at Duke University and published in the New England Journal of Medicine last year, patients placed on the heart-lung machine have a greater risk of suffering from side-effects such as a decline in intellectual function, stroke, transitory retinal damage, seizures, multiple organ dysfunction, and compromised immunity. In some cases the patient dies. "Heart-lung machine releases inflammatory molecules capable of harming organs throughout the body, including the brain," says Dr Reddy.
Since the beating heart surgery does not use a heart-lung machine it has lesser side-effects and surgery can be performed even on elderly patients with lung problems and kidney failure, who are unfit to undergo on-pump bypass. "At times, sick and elderly patients were considered unsuitable for coronary bypass surgery because they were too weak to withstand the rigours of the heart-lung machine." Incidentally, at 88 years and 11 months on the day of surgery, Raman is Dr Reddy's oldest patient to have undergone a beating heart surgery.
A British study, published in the April 6 issue of The Lancet, found significant advantages for off-pump patientsÑa 12 per cent reduction in chest infection, one-third reduction in red cell transfusions and a 25 per cent reduction in atrial fibrillation, a condition marked by dangerously irregular heartbeat. The other advantages of beating heart surgery include fewer days of hospitalisation. It is less expensive, tooÑwhile conventional surgery costs between Rs 1.20 lakh and Rs 1.60 lakh beating heart surgery costs nearly 25 per cent less.
"More importantly," says Dr Reddy, "whenever blood is put into the heart-lung machine, the patient needs to be put on anti-clotting medication since artificial circuits like the heart-lung machine can damage blood cells. These factors may affect the blood's ability to clot after surgery. Avoiding the heart-lung machine can alleviate this blood trauma."
"The surgery is a crucial team effort," says Dr P.S.N. Raju, chief anaesthetist at Vijaya Heart Foundation, adding that the responsibility of controlling blood pressure and other vital signs during the surgery is a virtual tightrope walk. The team at Vijaya Heart Foundation was strengthened after Padma Shri Dr K.A. Abraham, who was chief cardiologist at the All India Cardiac Centre, Railway Hospital, Perambur, for over 20 years, joined as senior consultant and interventional cardiologist. He is also attached to MIOT Cardiac Centre (MCC).
"The beating heart surgery can be easier on the patient than traditional bypass surgery," says Dr Reddy. "Our statistics reveal excellent results. I am an advocate of the off-pump surgery. Wherever I can do it without the pump, I will."
hope this will help and good luck for you and father
thanks
dan
