Conditions and Treatments

Multimedia health education

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Heart Anatomy	Angina Pectoris	Heart Attack
Heart Failure	Angioplasty	Endovascular Repair of Abdominal Aortic Aneurysm
Coronary Artery Bypass Graft (CABG)	Off-Pump Coronary Artery Bypass Surgery (OPCAB)	Mini-Maze Surgical Ablation for Atrial Fibrillation
Minimally Invasive Heart Valve Surgery	Carotid Artery Stenting

Heart

Normal Heart Anatomy
Heart Attack
Angina
Heart Failure
Coronary Artery Disease
Angioplasty
CABG
OPCAB
Valvular Heart Disease
Atrial Fibrillation
Mini-maze Surgery for Atrial Fibrillation
Minimally Invasive Heart Valve Surgery
Cardiac Myxoma and Tumors
DOR Procedure for CHF
Pacemaker Placement
Automatic Implantable Cardioverter Defibrillator
Endoscopic assisted LIMA to LAD Bypass
Transmyocardial Revascularization

Lung

Emypema
Video assisted Thoracoscopic Surgery
Thymectomy
Video assisted Thoracoscopic Lobectomy

Aorta/Vascular

Endovascular Repair of Abdominal Aortic Aneurysm
Endovascular repair of descending Thoracic Aneurysms

More

More Diseases and Treatments

Normal Heart Anatomy

The main function of the heart is to deliver oxygen-rich blood to every cell in the body.
The arteries are the passageways through which the blood is delivered and the veins are the passageways through which the blood is collected and returned to the heart.

The adult heart weighs between 200 to 425 grams (7 to 15 ounces) and is about the size of your fist. Your heart is a muscle, which unlike other muscles of the body has to work around the clock to keep your blood circulating.

To understand the anatomy and function of the heart, we have divided the heart into two sections - Exterior and Interior

Exterior Anatomy

Vena Cava

The vena cava is a large vein that brings deoxygenated (impure) blood back to the heart and empties it in to the right atriuma.

Atria

There are two atria, the right atrium, and the left atrium, which are the two upper chambers of the four muscular chambers of the heart.

The right atrium collects the impure blood from the vena cava and delivers it to the right ventricle. This delivery is regulated by the tricuspid valve.

The left atrium collects the oxygenated blood from the lungs, via the pulmonary veins and delivers it to the left ventricle. This delivery is regulated by the mitral valve.

Ventricles

There are two ventricles, right and left, which are the two lower chambers of the four muscular chambers of the heart.

The right ventricle collects the impure blood from the right atrium and delivers it to the lungs for purification (oxygenation). This delivery is regulated by the pulmonary valve.

The left ventricle collects the pure blood from the left atrium and delivers it to the aorta (main artery) from where it is pumped to the rest of the body. This delivery is regulated by the aortic valve.

Pulmonary Artery

As part of the pulmonary circulation, the pulmonary artery carries the de-oxygenated blood from the right ventricle to the lungs for oxygenation.

Pulmonary Veins

Blood after oxygenation in the lungs, is brought back to the heart by pulmonary veins and delivered to left atrium.

Aorta

The Aorta the largest artery in the body, collects blood pumped from the left ventricle to branch and deliver the oxygen rich blood to various organs and tissues in the human body.

Pericardium

The pericardium is the fluid filled sac that surrounds the heart. The heart literally floats in this pericardial fluid.

The main function of the pericardium is to:

• Keep the heart within the chest cavity.
• Act as a shock absorber preventing the heart from over expanding when blood volume increases.

Coronary Circulation

The coronary circulation consists of the blood vessels that supply blood to, and remove blood from, the heart tissue. Coronary arteries supply oxygen rich blood to the heart and the coronary veins remove the deoxygenated blood from the heart.

Serious heart damage may occur when the coronary circulation is blocked.

Coronary Arteries

Blood is supplied to the heart by the coronary arteries. Two main coronary arteries branch off the aorta then branch into several smaller arteries that supply oxygen rich blood to the heart.

Coronary Veins

The deoxygenated blood from the heart muscle is collected by the coronary veins and drained into the right atrium.

Circulatory system

The heart acts a pump, delivering blood to the organs, tissues, and cells of your body through a complex network of arteries, arterioles, and capillaries. Blood is returned to your heart through venules (small veins) and veins.

Interior Anatomy

Heartbeat

The heart is a pump and each contraction of the heart represents one heartbeat.

Pulse or Heart Rate is the number of heartbeats per minute.

The heart rate is controlled by the brain and varies depending on, factors such as age, stress, exercise, surrounding temperature, and hormones.

The heartbeat is a two part pumping action- Systole (contraction) and Diastole (relaxation). Move your cursor over the labels to find out more.

Systole (Ventricular Contraction)-

The series of activities in systole which happens at one particular moment are:

• The tricuspid and mitral valve shut to prevent backflow into the respective atria.
• Blood from the right ventricle is pumped to the lungs through the pulmonary artery.
• Blood from the left ventricle is pumped to the rest of the body through the aorta.
• The Vvena cava empties the deoxygenated blood into the right atrium.
• The pulmonary veins empty the oxygenated blood into the left atrium.

In a normal resting adult, the heart beats about 72 times per minute (Pulse 72), which means all the above activities happen in less than one second.

Diastole (Ventricular Relaxation)-

The series of activities in diastole which happens at one particular moment are:

• The tricuspid and the mitral valve open.
• Deoxygenated blood from the right atrium flows to the right ventricle.
• Oxygen rich blood from the left atrium flows to the left ventricle.

In a normal resting adult, the heart beats about 72 times per minute (Pulse 72), which means all the above activities happens in less than one second.

Heart Valves

The main function of the heart valves is to regulate and prevent the backflow of the blood.

There are four important valves in the heart.

Tricuspid Valve

The tricuspid valve regulates blood flow between the right atrium and the right ventricle.

It prevents the backflow of blood to the right atrium when the right ventricle pumps blood to the lungs.

Mitral Valve

The mitral valve regulates the blood flow between the left atrium and the left ventricle.

It prevents the backflow of blood to the left atrium when the left ventricle pumps blood through the aorta to the rest of the body.

Pulmonary Valve

The pulmonary valve regulates the de--oxygenated blood from the right ventricle to the lungs for purification.

Aortic Valve

The aortic valve regulates the oxygenated blood pumped from the left ventricle to the rest of the body.

Conduction System

The heart's pumping energy comes from a built-in electrical conduction system.

The sinoatrial node, SA node is called the heart's natural pacemaker that causes the atria to contract when the electrical impulse is released.

The signal is then passed on to the atrioventricular node, AV node, and then to the conduction pathways (bundle of His) to provide electrical stimulus to the ventricles.

Heart Attack

The coronary arteries supply blood to the heart muscle. When the coronary arteries become narrow or blocked, blood flow to the heart is reduced. This decrease in blood flow to the heart deprives the heart muscle of oxygen.

Heart attack (also called myocardial infarction) is when part of the heart muscle is damaged or dies because it isn't receiving oxygen. Most heart attacks are caused by a blockage in the coronary arteries.

If you suspect symptoms of heart attack, you should call for an ambulance or seek immediate medical attention.

The main function of the heart is to deliver the oxygen-rich blood to every cell in the body.

The arteries are the passageways through which the blood is delivered and the veins are the passageways through which the blood is collected and returned to the heart.

The coronary arteries supply blood to the heart muscle. When the coronary arteries become narrow or blocked, blood flow to the heart is reduced. This decrease in blood flow to the heart deprives the heart muscle of oxygen.

Heart attack (also called myocardial infarction) is when part of the heart muscle is damaged or dies because it isn't receiving oxygen.

Atherosclerosis

Atherosclerosis is a condition in which fatty material is deposited along the walls of arteries. This fatty material (often called plaque) thickens, hardens, and may eventually block the arteries.

Atherosclerosis of the coronary arteries is the most common cause of heart attack.

Risk factors

Risk factors for atherosclerosis and heart attack include

• Family history
• Hypertension (High Blood Pressure)
• High Cholesterol or other fat levels in blood
• Inactive lifestyle- Obesity/ overweight/ lack of exercise
• Diabetes (High blood sugar)
• Cigarette Smoking

How will you feel?

Chest pain is the most common complaint in heart attack. Unlike angina, pain does not subside on resting.

However, the symptoms may be different.

For example,

• Fullness, uncomfortable pressure, squeeze in the middle of the chest
• Tightness, burning or a heavy weight over your chest
• Pain may radiate to your shoulders, neck, arms, upper abdomen, back or jaw.

20% of the patients with heart attack have no pain. This is seen in diabetics, high blood pressure, and elderly patients.

Heart attack is a medical emergency and if you suspect symptoms of heart attack, you should call for an ambulance or seek immediate medical help.

Complications

Complications depend upon the location and extent of the heart damage (due to blocked blood supply). Early intervention and treatment could prevent these complications.

• Cardiac arrhythmias
  Cardiac arrhythmias are disruptions in the natural rhythm of the heartbeat.
• Cardiac Failure
  Here the heart fails to pump blood to meet the metabolic demands of the body.
• Pericarditis
  Pericarditis is the inflammation of the pericardium, the outer covering of the heart that acts as a shock absorber for the heart.
• Recurrent heart attacks
  Increased risk of heart attacks and angina in the future.
• Blood clots (Thromboembolism).
  Blood clots may be formed due to irregular rhythms and prolonged immobility. You may be prescribed blood-thinning agents that need to be monitored with regular blood tests.

Investigations

Heart attack is a medical emergency and if you suspect symptoms of heart attack, you should call for an ambulance or seek immediate medical help.

The following tests may be conducted in the emergency department or at the hospital.

• Blood tests
  Routine blood tests may be done for blood counts, electrolytes, cholesterol and cardiac enzymes. The cardiac enzymes in blood are markers of heart damage.
• (EKG or ECG) Electrocardiogram
  EKG is a test to measure the electrical activity of the heart and provides your doctor with information about your heart rate, rhythm, size of the heart chambers and previous damage to the heart. It is non-invasive and painless and is performed by attaching electrodes to various parts of the body.
• Nuclear heart scans.
  This test shows blood flow to the heart and any damage to the heart muscle. A radioactive dye is injected into your bloodstream. A special camera can see the dye and find areas where blood flow is reduced.
• Angiography (Cardiac Catheterization)
  Angiography is a test that enables your doctor to take x-ray images of the inside of your blood vessels. This procedure is performed by a cardiologist and involves threading a tiny catheter through a small incision into a large artery, usually in your groin. Once the catheter reaches the site of the blood vessel to be viewed, a dye is injected and x-ray images are taken. Angiography enables your doctor to view how blood circulates in the vessels in specific areas of the body.

Management

In angina, the blood supply to the heart is reduced and in heart attack the blood supply is blocked. Heart attack treatment should start as soon as possible to prevent complications and irreversible damage to the heart.

If heart attack is confirmed then immediate treatment may include

• Relieve anxiety and shock
• Pain relief
• Oxygen
• Thrombolytic treatment to break down the clot
• Medications to stabilize the heart rhythm
• Angioplasty or Surgery

General treatments include

• Lifestyle modifications
• Medications
• Surgery

Lifestyle Modifications

The following life style modifications can help to prevent or lower your risk for heart disease and heart attack and improve your heart health:

• Healthy Diet Choices-eating a low fat, low salt, low cholesterol diet
• Don't Smoke-If you do smoke, talk to your doctor about available options to help you quit. You will immediately lower your risk of heart disease as soon as you quit.
• Exercise- increasing your physical activity is a great way to reduce stress, improve sleep, lose weight, and improve your overall sense of well being. Always discuss with your doctor before beginning any new exercise program.
• Weight Loss-Being overweight puts extra strain on your heart. Discuss weight loss options with your doctor and follow his advice.
• Diabetes Control- Take your diabetic medications, check with your doctor for exercises and physical activity as well as nutrition advice.

Medications

Along with life style modification, medications may be needed to control symptoms and improve the heart health. More than one medication may be prescribed. Some common coronary artery disease medications are listed below.

• Anticoagulants or Thrombolytic agents- they are given during a heart attack to break up a blood clot in a coronary artery in order to restore blood flow.
• Aspirin: reduces the tendency of small blood cells called platelets to stick together, which helps prevent the formation of a thrombosis.
• Nitroglycerin (NTG) This quick acting sublingual tablets or spray relax the arteries of the heart and relieve angina attacks.
• Digitalis - makes the heart contract harder and is used when the heart's pumping function has been weakened; it also slows some fast heart rhythms.
• ACE (angiotensin converting enzyme) inhibitor - stops the production of a chemical that makes blood vessels narrow and is used to help control high blood pressure and in cases of heart failure.
• Long-acting nitrates reduce the frequency of angina attacks. These can be in the form of tablets or patches and are very effective. Their main side effect is headache, but this often disappears once the nitrate has been taken for some weeks.
• Beta-blockers work by slowing down the heart rate and decreasing the force of the heart muscle. This reduces the heart's need for oxygen and improves the supply of blood to the heart muscle.
• Calcium channel blockers reduce the frequency and severity of chest pain. They reduce the muscle tension in the coronary arteries, expanding them and creating more room. They also slightly relax the heart muscle, reducing the heart's need for oxygen and reducing blood pressure.

Surgery

When lifestyle changes and medications are not sufficient to control angina, your doctor may suggest surgery or invasive procedures. The following procedures improve blood flow to the heart to relieve the chest pain and may prevent a heart attack in the future.

• Angioplasty - In this procedure, a thin tube is threaded into the coronary arteries via a blood vessel in the groin, in a similar procedure to cardiac catheterization. A small balloon attached to the end of the tube is inflated, which widens the blocked portion of the artery and allows increased blood flow to the affected part of the heart muscle. Angioplasty may be done with or without stenting.
• Coronary Artery Bypass Graft (CABG surgery) - the coronary artery blockage is bypassed with a section of vein taken from the leg or from the forearm. Cardiac Rehabilitation

  Cardiac rehabilitation is a clinically supervised program to help heart patients recover and regain their overall physical and mental functioning. This helps to prevent recurrent heart attacks.

• Cardiac rehabilitation programs include education about cardiac health, lifestyle modifications, psychological support, nutritional advice and much more.

Prevention

The following life style modifications can help to prevent or lower your risk for heart disease and heart attack and improve your heart health:

• Understand all about heart attack, risk factors, symptoms, related conditions, etc.
• Healthy Diet Choices-eating a low fat, low salt, low cholesterol diet
• Don't Smoke-If you do smoke, talk to your doctor about available options to help you quit. You will immediately lower your risk of heart disease as soon as you quit.
• Exercise- increasing your physical activity is a great way to reduce stress, improve sleep, lose weight, and improve your overall sense of well being. Always discuss with your doctor before beginning any new exercise program.
• Weight Loss-Being overweight puts extra strain on your heart. Discuss weight loss options with your doctor and follow his advice.
• Treat related conditions, such as high blood cholesterol, high blood pressure, diabetes, obesity & overweight.
• Regular health checkup and follow your doctors advice.

Heart disease is preventable and the actions you take to reduce your risk of heart disease by making lifestyle changes will increase your chances for a long and healthy life.

Angina

ANGINA PECTORIS ("ANGINA") is a recurring pain or discomfort in the chest that happens when some part of the heart does not receive enough blood.

Angina is a common symptom of coronary artery disease that occurs when the coronary arteries are narrowed or blocked. It is usually relieved within a few minutes by resting or by taking prescribed angina medicine.

Important Note: Not all chest pain is angina and therefore should always be evaluated by a Physician.

The main function of the heart is to deliver oxygen-rich blood to every cell in the body.
The arteries are the passageways through which the blood is delivered and the veins are the passageways through which the blood is collected and returned to the heart.

The coronary arteries supply blood to the heart muscle. When the coronary arteries become narrow or blocked, blood flow to the heart is reduced. This decrease in blood flow to the heart deprives the heart muscle of oxygen. The heart responds to the lack of oxygen by sending out signs in the form of pain called angina.

Atherosclerosis

Atherosclerosis is a condition in which fatty material is deposited along the walls of arteries. This fatty material (often called plaque) thickens, hardens, and may eventually block the arteries.

Atherosclerosis of the coronary arteries is the most common cause of angina.

Risk factors

Risk factors for atherosclerosis and angina include:

• Family history
• Hypertension (High Blood Pressure)
• High cholesterol or other fat levels in blood
• Inactive lifestyle- Obesity/ overweight/ lack of exercise
• Diabetes (High blood sugar)
• Cigarette smoking

Triggers

Physical exertion is the most common trigger for angina.

Others triggers include:

• Emotional stress
• Extreme cold or heat
• Heavy meals
• Alcohol consumption and cigarette smoking.

How will you feel?

Chest pain is the most common complaint in angina. However, the symptoms may be different.

For example:

• Fullness, uncomfortable pressure, squeezing sensation in the middle of the chest
• Tightness, burning, or a heavy weight over your chest
• Pain may radiate to your shoulders, neck, arms, upper abdomen, back or jaw.

Important Note: Not all chest pain is angina and therefore should always be evaluated by a Physician.

Diagnoses

To diagnose angina, your doctor may use one of more of the following:

• Medical History
  This includes:
  Physical examination
  Questions about your symptoms, risk factors, personal history, and family history of any heart disease.
• (EKG or ECG) Electrocardiogram
  EKG is a test to measure the electrical activity of the heart and provides your doctor with information about your heart rate, rhythm, size of the heart chambers and previous damage to the heart. It is non-invasive and painless and is performed by attaching electrodes to various parts of the body.
• Exercise Tolerance Test (Stress EKG or Stress ECG or Stress Test)
  A stress EKG is basically an EKG that is performed while the patient is exercising on a treadmill or a stationary bike. It allows your doctor to see how your heart functions under stress and tells him how healthy your heart is.
• Nuclear heart scans.
  This test shows blood flow to the heart and any damage to the heart muscle. A radioactive dye is injected into your bloodstream. A special camera can see the dye and find areas where blood flow is reduced.
• Stress Echocardiogram
  A stress echocardiogram allows your doctor a more visual view of your heart. An echocardiogram creates still and moving pictures of your heart at rest by bouncing sound waves off the heart from a device called a transducer. The waves are then used to create a picture of your heart. During a stress echocardiogram, your doctor will perform an echocardiogram while you are resting and then again after you have exercised on a treadmill or stationary bike. The information allows the doctor to learn more about the muscles, valves and other structures of the heart.
• Angiography (Cardiac Catheterization)
  Angiography is a test that enables your doctor to take x-ray images of the inside of your blood vessels. This procedure is performed by a cardiologist and involves threading a tiny catheter through a small incision into a large artery, usually in your groin. Once the catheter reaches the site of the blood vessel to be viewed, a dye is injected and x-ray images are taken. Angiography enables your doctor to view how blood circulates in the vessels in specific areas of the body.

Management

• Lifestyle modifications
• Angina medications
• Surgery

Lifestyle Modifications

The following life style modifications can help to prevent or lower your risk for heart disease and angina and improve your heart health:

• Healthy Diet Choices-eating a low fat, low salt, low cholesterol diet
• Don't Smoke-If you do smoke, talk to your doctor about available options to help you quit. You will immediately lower your risk of heart disease as soon as you quit.
• Exercise- increasing your physical activity is a great way to reduce stress, improve sleep, lose weight, and improve your overall sense of well being. Always discuss with your doctor before beginning any new exercise program.
• Weight Loss-Being overweight puts extra strain on your heart. Discuss weight loss options with your doctor and follow his advice.

Angina Medications

Along with life style modification, medications may be needed to control symptoms and improve the heart health. More than one medication may be prescribed. Some common angina medications are listed on the left. Move your cursor over the medications to find out more.

• Aspirin: reduces the tendency of small blood cells called platelets to stick together, which helps prevent the formation of a blood clot (thrombosis).
• Nitroglycerin (NTG) This quick acting sublingual tablet or spray relax the arteries of the heart and relieve angina attacks.
• Long-acting nitrates reduce the frequency of angina attacks. These can be in the form of tablets or patches and are very effective. Their main side effect is headache, but this often disappears once the nitrate has been taken for some weeks.
• Beta blockers work by slowing down the heart rate and decreasing the force of the heart muscle. This reduces the heart's need for oxygen and improves the supply of blood to the heart muscle.
• Calcium channel blockers reduce the frequency and severity of chest pain. They reduce the muscle tension in the coronary arteries, expanding them and creating more room. They also slightly relax the heart muscle, reducing the heart's need for oxygen and reducing blood pressure. Surgery

When lifestyle changes and medications are not sufficient to control angina, your doctor may suggest surgery or invasive procedures. The following procedures improve blood flow to the heart to relieve the chest pain and may prevent a heart attack in the future.

• Angioplasty - In this procedure, a thin tube is threaded into the coronary arteries via a blood vessel in the groin, in a similar procedure to cardiac catheterization. A small balloon attached to the end of the tube is inflated, which widens the blocked portion of the artery and allows increased blood flow to the affected part of the heart muscle. Angioplasty may be done with or without stenting.
• Coronary Artery Bypass Graft CABG surgery - the coronary artery blockage is bypassed with a section of vein, taken from the leg or from the forearm.

Prevention

Healthy life choices will improve your overall health and your heart health and can help you slow the progression of your heart disease. Some heart healthy choices include:

• Understand all about angina, risk factors, symptoms, related conditions, etc.
• Healthy Diet Choices-eating a low fat, low salt, low cholesterol diet
• Don't Smoke-If you do smoke, talk to your doctor about available options to help you quit. You will immediately lower your risk of heart disease as soon as you quit.
• Exercise- increasing your physical activity is a great way to reduce stress, improve sleep, lose weight, and improve your overall sense of well being. Always discuss with your doctor before beginning any new exercise program.
• Weight Loss-Being overweight puts extra strain on your heart. Discuss weight loss options with your doctor and follow his advice.
• Regular health screenings and following your doctor's advice.

Heart disease is preventable and the actions you take to reduce your risk of heart disease by making lifestyle changes will increase your chances for a long and healthy life.

Heart Failure

Heart failure is a condition where the heart fails to pump blood in order to maintain the metabolic needs of the body. In most cases heart failure is a chronic, long-standing, and ongoing condition but it can develop suddenly.

Causes

Heart failure results when the over worked heart muscle does not work as efficiently as it used to. Any factor that increases the heart workload may initiate heart failure. It is most commonly seen in old age and common causes are:

• Coronary Artery Disease- causes narrowed arteries that decrease the blood supply to the heart muscle.
• Previous heart attack- interferes with the heart muscle's normal functioning.
• High blood pressure- causes the heart to work harder than usual. Other causes of heart failure include
• Valvular heart disease e.g., Aortic Stenosis
• Congenital heart defects
• Cardiomyopathy- disease of the heart musle
• Lung disease
• Arrythmias- irregular heartbeat
• Alcoholism

How will you feel?

The "failing" heart keeps working but not as efficiently as it should. People with heart failure can't exert themselves because they become short of breath and tired.

Symptoms include

• Fatigue
• Breathlessness and difficulty in breathing
• Weight gain due to fluid retention
• Inability to lie flat in bed due to fluid retention in lungs
• Swelling in legs (edema)

It is useful to consult a doctor if you feel fatigue or sudden weight gain.

Aggravating factors

Any factor that increases the heart workload may aggravate existing heart failure or initiate heart failure.

Some aggravating factors are

• Arrhythmias (irregular heart beat)
• Anemia (decreased hemoglobin in blood)
• Hormonal factors e.g., increased thyroid hormone
• Pregnancy

Compensatory mechanisms

The heart is a vital organ that helps pump blood to every organ in the body. When the heart fails considerable changes occur in the heart as well as other organs as fluid starts accumulating.

Some major changes are

• Heart
  The heart tries to compensate by increasing the blood flow from the heart and the heart size may increase.
• Lungs
  Swelling and fluid accumulation in the lungs (Pulmonary edema) and hence difficulty in breathing.
• Kidney
  Kidneys begin to lose their normal ability to excrete salt (sodium) and water. As a result, the kidneys may begin to fail.
• Liver
  Fluid accumulation in the liver impairs its ability to excrete toxins from the body and produce essential proteins. Over time, untreated heart failure will affect virtually every organ in the body.

Diagnoses

Your doctor diagnoses Heart failure by medical history alone but may ask you to undergo a series of diagnostic tests.

• Medical History
  which includes
  • Physical examination
  • Questions about your symptoms, risk factors, personal history and family history of any heart disease.
• Chest X-ray
  A chest x-ray can show if your heart is enlarged and if you have fluid in and around your lungs.
• (EKG or ECG) Electrocardiogram
  This is a painless test where electrodes are put on the chest, arms, and legs to record the heart's electrical activity. The test takes just a few minutes and the record of the heart appears as a long strip of paper, or a graph with a series of wavy lines. The EKG gives a physician important information about your heart's rate and rhythm, and can provide evidence to suggest the presence of a past or current heart attack.
• Echocardiogram
  Echocardiogram is a test that uses sound waves to create a moving picture of the heart. The picture is much more detailed than x-ray images and involves no radiation exposure. These ultrasound images help identify abnormalities in the heart muscle and valves, and find any fluid that may surround the heart. You can see your ventricles squeeze and relax, and watch the valves open and close in rhythm with your heartbeat.
• Nuclear heart scans.
  This test shows blood flow to the heart and any damage to the heart muscle. A radioactive dye is injected into your bloodstream. A special camera can see the dye and find areas where blood flow is reduced.
• Angiography (Cardiac Catheterization)
  Cardiac Catheterization is a specialized test that is performed by a cardiologist in a cardiac catheterization lab. The procedure is done by making a small incision in the groin or arm area, and threading a very small catheter up through the artery to the heart. A radioactive dye is injected and then blockages to coronary arteries can clearly be seen. The test takes about 2-3 hours, and is done with local anesthetics and sedation. This test reveals clear pictures of blockages or narrowing of the coronary arteries, and can tell how efficient your heart is working as well.

Management

Heart failure management should start soon after diagnosis and includes the following

• General Management
• Medications
• Surgery

General Management

• Reduction of physical activity- to reduce demand on the heart
• Dietary modifications- low salt diet
• Losing weight if overweight
• Quitting smoking
• Alcohol restriction

Heart failure medications

Heart failure drugs include.

• Diuretics- promote salt and water excretion by the kidneys thereby reducing the heart workload and symptoms of fluid retention. They help relieve shortness of breath and leg swelling.
• Beta blockers- work by slowing down the heart rate and decreasing the force of the heart muscle. This reduces the heart's need for oxygen and improves the supply of blood to the heart muscle.
• ACE inhibitors- these medications open up blood vessels and decrease the work load of the heart.
• Digoxin (Digitalis Glycosides) - increases the ability of the heart muscle to contract properly and prevent heart arrythmias.

Surgery

Cardiac Transplantation

Cardiac transplantation is the process of removing a person's failing heart and replacing it with a suitable donor heart. The donor heart is usually from a person who has been declared clinically brain dead.

It is recommended in younger patients with severe heart failure and life expectancy less than 6 months.

Prevention

Healthy life choices will improve your overall health and your heart health and can help you slow the progression of your heart disease. Some heart healthy choices include:

• Understand all about heart failure, symptoms, related conditions, etc.
• Eat Healthy- Stick to a heart-healthy low cholesterol, low fat, and low sodium diet.
• Quit smoking- No matter how long you have smoked, when you quit, you lower your risk for heart disease. Also stop using any smokeless tobacco products as the chemicals in them affect the heart as well.
• Exercise - Exercising and being active are important and can reduce stress and help you sleep. Walking is always an easy way to begin. Check with your doctor before starting any new exercise program.
• Lose weight- If you are considered overweight or obese talk with your doctor about the best way for you to shed the extra pounds.
• Treat related conditions- such as high cholesterol, high blood pressure, diabetes, obesity, and being overweight.
• Regular health screenings and following your doctor's advice.

Coronary Artery Disease

What is Coronary Artery Disease?

Coronary Artery Disease (CAD) is usually caused from a condition called atherosclerosis. Atherosclerosis is a condition in which fatty material is deposited along the walls of arteries. This fatty material (often called plaque) thickens, hardens, and may eventually block the arteries.

When atherosclerosis occurs within the coronary arteries, the condition is referred to as Coronary Artery Disease, or CAD.

Symptoms of CAD include chest pain (angina), shortness of breath, and, if left untreated, heart attack.

CAD is the most common cause of angina and Heart Attack.

Risk factors for Coronary Artery Disease include the following:

• Family history
• Hypertension (High Blood Pressure)
• High Cholesterol or other fat levels in blood
• Inactive lifestyle- Obesity/ overweight/ lack of exercise
• Diabetes (High blood sugar)
• Cigarette Smoking
• Stress
• Menopause
• Non-compliance with medicines to treat hypertension and high cholesterol.

Coronary Heart Disease is the most common cause of Angina and Heart Attack.

Symptoms

Chest pain is the most common complaint in heart attack. Unlike angina, pain does not subside on resting.

However, the symptoms may be different.

For example,

• Fullness, uncomfortable pressure, squeeze in the middle of the chest
• Tightness, burning or a heavy weight over your chest
• Pain may radiate to your shoulders, neck, arms, upper abdomen, back or jaw.

20% of the patients with heart attack have no pain. This is seen in diabetics, high blood pressure, and elderly patients.

Heart attack is a medical emergency and if you suspect symptoms of heart attack, you should call for an ambulance or seek immediate medical help.

Diagnoses

A Cardiologist should evaluate all heart conditions for proper diagnosis and treatment.

Your Cardiologist will perform the following:

• Medical History
• Physical Examination

Diagnostic Studies may include:

• Blood tests
  Routine blood tests may be done for blood counts, electrolytes, cholesterol and cardiac enzymes. The cardiac enzymes in blood are markers of heart damage.
• (EKG or ECG) Electrocardiogram
  EKG is a test to measure the electrical activity of the heart and provides your doctor with information about your heart rate, rhythm, size of the heart chambers and previous damage to the heart. It is non-invasive and painless and is performed by attaching electrodes to various parts of the body.
• Nuclear heart scans
  This test shows blood flow to the heart, any damage to the heart muscle, and how well your heart pumps blood to the rest of your body. A radioactive dye is injected into your bloodstream. A special camera can see the dye and find areas where blood flow is reduced to the heart muscle, which may indicate the presence of CAD.
• Angiography (Also called Angiogram or Cardiac Catheterization)
  Angiography is a test that enables your doctor to take x-ray images of the inside of your blood vessels. This procedure is performed by a cardiologist and involves threading a tiny catheter through a small incision into a large artery, usually in your groin. Once the catheter reaches the site of the blood vessel to be viewed, a dye is injected and x-ray images are taken. Angiography enables your doctor to view how blood circulates in the vessels in specific areas of the body. An angiogram is the only test that shows the blood vessels of the heart.

Management of Coronary Artery Disease includes:

• Lifestyle Modifications
• Medications

Lifestyle Modifications

Healthy life choices will improve your overall health and your heart health and can help you slow the progression of your heart disease. Some heart healthy choices include:

• Healthy Diet Choices-Eating a low fat, low salt, low cholesterol diet
• Don't Smoke-If you do smoke, talk to your doctor about available options to help you quit. You will immediately lower your risk of heart disease as soon as you quit.
• Exercise- Increasing your physical activity is a great way to reduce stress, improve sleep, lose weight, and improve your overall sense of well-being. Always discuss with your doctor before beginning any new exercise program.
• Weight Loss-Being overweight puts extra strain on your heart. Discuss weight loss options with your doctor and follow his advice.
• Diabetes Control- Take your diabetic medications, check with your doctor for exercises and physical activity as well as nutrition advice.

Medications

Along with life style modification, medications may be needed to control symptoms and improve the heart health. More than one medication may be prescribed. Some common medications are listed on the left. Move your cursor over the medications to find out more.

• Anticoagulants or Thrombolytic agents - These blood thinning medicines are given during a heart attack to break up a blood clot in a coronary artery in order to restore blood flow.
• Aspirin: Aspirin reduces the tendency of small blood cells called platelets to stick together, which helps prevent the formation of a blood clot (thrombosis).
• Nitroglycerin (NTG): This quick acting sublingual tablet or spray relax the arteries of the heart and relieve angina attacks. Sublingual means it is administered under the tongue for quick absorption and action.
• Digitalis - Digitalis makes the heart contract harder and is used when the heart's pumping function has been weakened; it also slows some fast heart rhythms.
• ACE (angiotensin converting enzyme) inhibitor - Ace Inhibitors stops the production of a chemical that makes blood vessels narrow and is used to help control high blood pressure and in cases of heart failure.
• Long-acting nitrates: Long-acting nitrates reduce the frequency of angina attacks. These can be in the form of tablets or patches and are very effective. Their main side effect is headache, but this often disappears once the nitrate has been taken for some weeks.
• Beta-blockers: Beta-blockers work by slowing down the heart rate and decreasing the force of the heart muscle. This reduces the heart's need for oxygen and improves the supply of blood to the heart muscle.
• Calcium Channel Blockers: Calcium Channel Blockers reduce the frequency and severity of chest pain. They reduce the muscle tension in the coronary arteries, expanding them and creating more room. They also slightly relax the heart muscle, reducing the heart's need for oxygen and reducing blood pressure.

Angioplasty

Angioplasty is a medical procedure used to treat narrowing of the arteries that supply blood to the heart. This is accomplished by inflating a small balloon inside the artery to increase the blood flow to the heart. It may be performed on an emergency basis following a heart attack, or on an elective basis when conservative treatment measures have failed to relieve symptoms of Coronary Artery Disease such as chest pain and shortness of breath.

Angioplasty Procedure

If conservative treatment options are unsuccessful and you continue to have chest pain or are at risk of having a heart attack, your cardiologist may recommend a procedure called balloon angioplasty.

Angioplasty is performed by an Interventional Cardiologist in the Cardiac Catheterization Lab of the hospital under local anesthesia and IV sedation. You will be awake but relaxed and drowsy.

During Angioplasty, the patient is placed lying on their back on an x-ray table.

The catheter insertion area, groin or arm, is shaved, disinfected, and injected with a local anesthetic to numb the area.

Your Cardiologist will perform an angiogram first to determine the extent and location of blockage within the coronary arteries prior to proceeding to an angioplasty.

Your surgeon will make a tiny cut over the insertion site and insert a small tube called a sheath into a blood vessel in the groin (or arm, depending on your surgeon's preference).

A flexible tube called a catheter is then gently passed through the sheath into the vessel until the blockage is reached.

A special dye is then injected through the catheter and into the artery so x-ray pictures can be obtained showing the location and extent of the blockage.

At this point, the cardiologist can proceed with the Angioplasty.

Your cardiologist will now insert a guide wire through the catheter advancing it across the blockage.

The catheter with a deflated balloon on its end is then threaded over the guide wire into the blockage.

The balloon is then inflated to push the plaque against the artery walls. This opens up the artery allowing increased blood flow to the heart.

Your cardiologist may deflate and inflate the balloon more than once within an artery to ensure the best result.

Often, the cardiologist will place a stent within the artery. A stent is a wire mesh tube placed within the artery to help keep the artery open. The stent is placed over the deflated balloon at the tip of the catheter before inserting the catheter into the blockage. When the balloon is inflated, the stent is pushed in place against the artery wall. Some stents are coated with medicine to keep blood clots from forming or the artery from closing.

Once your doctor is satisfied with the results, the balloon is deflated and the guide wire and catheter are withdrawn. The stent remains in place within the artery.

Pressure will be applied to the insertion site for 15 minutes followed by a tight pressure bandage to prevent bleeding.

Post Operative Guidelines

After Angioplasty you will be taken to the recovery room and be told to lie still for 6-8 hours to prevent bleeding from the puncture site. If the puncture site was performed in the arm area, you will be able to get out of bed.

Recovery time varies depending on whether your procedure was an angiogram or an angiogram with angioplasty. If only an angiogram was done, you may be able to go home with a driver after a few hours. If angioplasty was performed, you will likely spend 1-2 days in the hospital.

Common post-operative guidelines following Angioplasty include the following:

• You will need someone to drive you home after you are released. You should not drive for 1-2 days after the procedure.
• Do not remove the dressing over the puncture site until instructed to do so. Keep the area clean and dry.
• Your surgeon may give you activity restrictions such as no heavy lifting for a few days to prevent bleeding from reoccurring.
• You may have soreness and bruising around the puncture site.
• If a stent is placed, your doctor will prescribe blood-thinning medicines to prevent blood clots from forming around the stent. It is very important that you adhere to your prescribed medications to prevent blood clots from forming.

Contact your doctor immediately if you have a fever, chills, redness, bleeding, irregular heart beat, chest pain, shortness of breath, weakness, or dizziness.

Risks & Complications

• As with any medical procedure there are potential risks involved. The decision to proceed with the procedure is made because the advantages outweigh the potential disadvantages.
• It is important that you are informed of these risks before the procedure takes place.

Most patients do not have complications after Angioplasty; however complications can occur and depend on what type of procedure your doctor performs as well as the patient's health status. (i.e. obese, diabetic, smoker, etc.)

Complications can be medical (general) or specific to Angioplasty.

Medical complications include those of the anesthesia and your general well being. Almost any medical condition can occur so this list is not complete. Complications include:

• Allergic reaction to medications or dye
• Blood loss requiring transfusion with its low risk of disease transmission
• Heart attack, strokes, kidney failure, pneumonia, bladder infections
• Complications from insertion site such as infection or nerve damage
• Serious medical problems can lead to ongoing health concerns, prolonged hospitalization, or rarely death.

Specific complications for Angioplasty include:

• Bleeding from the insertion site
• Irregular heart beat
• Chest pain during procedure
• Blood vessel damage from the catheter requiring an operation for repair.
• Kidney damage from dye used with angiogram
• Restenosis- usually occurring within 6 months, restenosis is the re-accumulation of plaque or scar tissue causing narrowing or blockage again of the coronary artery. This risk is lessened with the use of a stent.
• Blood clots
• Stent moves from its placed location
• Need for an emergency Coronary Artery Bypass Graft (CABG or open heart surgery)

Risk factors that can increase the chance of complications following angioplasty include:

• Diabetes, especially if taking a medication called Glucophage.
• Women are at higher risk than men to develop complications.
• History of kidney disease
• Poor cardiac function
• Extensive heart disease
• Poor nutrition
• Smoking
• Obesity
• Age (over 75)
• Alcoholism
• Chronic Illness
• Steroid Use

Coronary Artery Bypass Graft Surgery (CABG)

Coronary Artery Bypass Graft Surgery, also called CABG or "cabbage", is a surgery used to treat narrowed or blocked arteries that supply blood to the heart. This is accomplished by going around or "bypassing" the blocked artery to increase the blood flow to the heart. It may be performed on an emergency basis following a heart attack, or on an elective basis when conservative treatment measures have failed to relieve symptoms of Coronary Artery Disease such as chest pain and shortness of breath. To learn more about Coronary Bypass Surgery, let us first learn about the normal anatomy of the heart.

What is CABG?

Coronary Artery Bypass Graft Surgery, also called CABG or "cabbage", is a surgery used to treat narrowed or blocked arteries that supply blood to the heart. This is accomplished by going around or "bypassing" the blocked artery with a healthy vessel called a "graft" that is taken from the leg, arm or chest. The graft will now carry the blood around the blockage to improve the blood flow to the heart.

A CABG may be performed on an emergency basis following a heart attack, or on an elective basis when conservative treatment measures have failed to relieve symptoms of Coronary Artery Disease such as chest pain and shortness of breath.

Coronary Bypass surgery is performed by Cardio-Thoracic surgeons in the operating room under general anesthesia. The operation usually takes about 3 hours but may be longer depending on the number of bypasses to be done.

"Open Heart Surgery" is a common name referring to the traditional method of performing CABG surgery. Many lay people believe the heart is "opened up" in "open heart surgery". However, this is not the case. The name refers to the fact that the surgery is performed through a large, open, chest incision. The surgery is actually performed on the vessels on the outside of the heart.

Some surgeons, however, are performing minimally invasive CABG (MICABG) through tiny incisions called portals enabling a quicker recovery time with decreased trauma to the tissues and bones. This surgery is not yet widely available and research is ongoing to evaluate and improve minimally invasive techniques.

The goal of Coronary Artery Bypass Graft surgery is:

• To relieve symptoms of CAD
• Improve blood flow to the heart
• To lengthen the patient's life

During a CABG, the patient is placed lying on their back on the operating table. The chest and graft area are shaved and scrubbed with antiseptic. You will be given a general anesthetic so you will be asleep and not feel any pain.

• Your surgeon will make a long incision down the middle of your chest bone (sternum). Special instruments called retractors are used to spread the ribs apart so the surgeon can access the heart.
• At the same time, another surgeon will "harvest" (remove) a vessel from either your arm (radial artery) or leg (long saphenous vein) to be used as the graft. This may be done through a large "open" incision or endoscopically through a much smaller incision.
• Your surgeon may choose to use an artery in the chest called the internal thoracic artery. In this case you will not have a "graft site" incision on your arm or leg unless you are having multiple bypasses performed.
• You will usually be given medicine or electric shocks to stop the heart so your surgeon can perform surgery while the heart is still. Some surgeons however perform the surgery with the heart beating but stabilized with clamps.
• If your heart is stopped your blood will be redirected to a machine called a heart lung machine. This is referred to as cardiopulmonary bypass. This machine does the work of your heart and lungs while your heart is stopped by adding oxygen to your blood and keeping your circulation moving.
• If a leg or arm graft is used the surgeon then attaches one end of the graft with fine sutures to the Aorta.
• The other end of the graft is then attached to the coronary artery beyond the blockage. This enables the blood to "bypass" the blockage and flow freely to the heart.
• If the internal thoracic artery is used, your surgeon will redirect the artery by detaching one end of it and reattaching it below the blockage on the coronary artery.
• Once your surgeon has completed the number of bypasses needed, your heart will be restarted with controlled electrical shocks and you will be removed from the bypass machine.
• The surgeon will use wires to reattach the sternum and suture the incision closed, usually with dissolvable sutures. Post Operative Guidelines

After Coronary Bypass surgery you will be taken to the intensive care unit (ICU) for monitoring for 1-2 days.

You will probably have a tube in your throat connected to a respirator for the first day or so to help you breathe. You will not be able to speak while the tube is in place.

You will have drain tubes in your chest to help drain blood and fluids.

You will likely spend 5-7 days in the hospital.

Common post-operative guidelines following Coronary Bypass surgery include the following:

• You will need someone to drive you home after you are released from the hospital. You should not drive for 4-6 weeks after the surgery. If you drive commercially, you will usually have to wait 3 months.
• You will be given instructions on care of your incisions. Normally, you will be able to shower without restrictions.
• Expect significant fatigue for the first two weeks after your surgery. This is common and will improve gradually over the next month.
• Your surgeon will give you activity restrictions such as no heavy lifting or strenuous exercise for the first 4-6 weeks to allow the sternum to heal completely.
• You will usually be able to resume sexual activity after 3-4 weeks.
• You may be able to return to work in 6-8 weeks depending on the type of work you do.
• You will have soreness and bruising around the incision and graft sites for the first month or so. You may hear a clicking sound in the chest while the sternum is healing. You will probably have chest pain with sudden movement, coughing, or sneezing. Be assured this is usually musculoskeletal pain and not angina. Your doctor will prescribe pain medications for you to take at home.
• Your doctor will prescribe blood-thinning medicines to prevent blood clots. It is very important that you adhere to your prescribed medications to prevent blood clots from forming.
• It is common to feel depressed after heart surgery. Talk with your doctor, as treatment is available through medication or therapy.
• Sleep disturbances are commonly reported. Again, discuss your concerns with your doctor should you have problems sleeping.
• You will be referred to a cardiac rehabilitation program to educate and assist you with your recovery. This usually involves exercise, lifestyle modification, and monitoring.
• It is important to know abnormal symptoms to report: Contact your doctor immediately if you have a fever, chills, purulent drainage from incisions, redness, bleeding, irregular heart beat, chest pain, shortness of breath, weakness, or dizziness.

Risks & Complications

• As with any medical procedure there are potential risks involved. The decision to proceed with the procedure is made because the advantages outweigh the potential disadvantages.
• It is important that you are informed of these risks before the procedure takes place.

Most patients do not have complications after Coronary Artery Bypass Graft surgery; however complications can occur and depend on what type of surgery your doctor performs as well as the patient's health status. (i.e. obese, diabetic, smoker, etc.)

Complications can be medical (general) or specific to Coronary Bypass surgery.

Medical complications include those of the anesthesia and your general well being. Almost any medical condition can occur so this list is not complete. Complications include:

• Allergic reaction to medications or dye
• Blood loss requiring transfusion with its low risk of disease transmission
• Heart attack, strokes, kidney failure, pneumonia, bladder infections
• Complications from nerve blocks such as infection or nerve damage
• Serious medical problems can lead to ongoing health concerns, prolonged hospitalization, or rarely death.

Specific complications for Coronary Artery Bypass Graft surgery include:

• Heart Attack
• Stroke
• Bleeding
• Deep wound infection requiring IV antibiotics and possible surgical debridement.
• Arrhythmia (Irregular heart beat)
• Nerve damage causing weakness, neuropathy, or paralysis.
• Blood vessel damage requiring an operation for repair.
• Vein graft occlusion or stenosis
• Recurrent Angina
• Blood clots
• Death (less than 3%)

Risk factors that can increase the chance of complications following a CABG include:

• Diabetes
• History of kidney disease
• Poor cardiac function
• Extensive heart disease
• Poor nutrition
• Smoking
• Obesity
• Age (over 60)
• Alcoholism
• Chronic Illness
• Steroid Use

Off Pump Coronary Artery Bypass Graft Surgery (OPCAB)

What is OPCAB?

If conservative treatment options for coronary artery disease are unsuccessful and you continue to have chest pain or are at risk of having a heart attack, your cardiologist may refer you to a Cardiothoracic surgeon for coronary artery bypass surgery. One type of bypass surgery that may be recommended is called Off-Pump Coronary Artery Bypass.

Off-Pump Coronary Artery Bypass (OPCAB), also called "Beating Heart" surgery, is an operation to treat narrowed or blocked coronary arteries. This is accomplished by going around or "bypassing" the blocked artery with a healthy vessel called a "graft" that is taken from the leg, arm or chest. The graft will now carry the blood around the blockage to improve the blood flow to the heart muscle.

Traditionally, coronary artery bypass surgery is performed with the heart stopped and the patient on a heart-lung bypass pump. The pump's function is to oxygenate and circulate the blood while the heart is stopped. This is referred to as cardiopulmonary bypass or CPB. Because there are certain risks associated with CPB, specially trained Cardiothoracic surgeons are now performing bypass surgery "off-pump", meaning without the bypass machine.

OPCAB surgery is open-heart surgery performed without the patient on cardiopulmonary bypass (CPB) and with the heart still beating.

"Open Heart Surgery" is a common term used when referring to Coronary Artery Bypass surgery. Many people believe the heart is "opened up" in "open heart surgery". However, this is not the case. The name actually refers to the fact that the surgery is performed through a large, open, chest incision. Since the surgery is actually performed on the vessels on the outside of the heart there is no need to cut the heart open.

Some surgeons are performing minimally invasive coronary bypass surgery (MICABG) through tiny incisions called portals enabling a quicker recovery time with decreased trauma to the tissues and bones. This surgery is not yet widely available and research is ongoing to evaluate and improve minimally invasive techniques.

Risks of CPB

Cardiopulmonary bypass or CPB has been shown to have associated risks. Some risks that may be related to CPB include:

• Neurocognitive Changes: Impaired mental capability including memory loss, decreased attention span, depression etc.
• CVA or Stroke: The risk of CVA while on CPB is believed to be from micro-embolisms of air or debris that block blood flow to the brain.
• Systemic Inflammation Response Syndrome (SIRS): A serious condition causing inflammation throughout the whole body that may lead to multiple organ failure and shock.
• Coagulopathy: A defect in the blood clotting ability of the body causing heavy and prolonged bleeding.
• Pulmonary Dysfunction: Respiratory problems including increased work of breathing, shallow breaths, hypoxemia (low blood oxygen), and ineffective coughing. Benefits of OPCAB surgery may include:
• Lessens the risks associated with the use of cardiopulmonary bypass pump.
• Less blood loss and need for transfusions post operatively
• Lower rate of wound infections
• Lower incidence of kidney complications
• Avoidance of systemic inflammatory response syndrome (SIRS)
• Decreased risk of Atrial Fibrillation (irregular, fast, ineffective heart beat)
• Faster recovery
• Shorter operating time
• Shorter hospital stay
• Less costly than traditional coronary bypass surgery.

OPCAB surgery is not for everyone and your surgeon will discuss with you whether this surgery is a good option for your particular situation.

Candidates for OPCAB may include the following:

• Elderly patients (over 70) with multiple diseased vessels
• Patients with lung disease such as COPD or emphysema.
• Patients with kidney disease or who are on dialysis.
• Patients with a high risk of stroke (CVA) or with a previous history of stroke or transient ischemic attacks (TIA or "mini-stoke)
• Patients with a low EF (ejection fraction) indicating poor heart function
• Patients with heavy atherosclerosis in the aorta
• Immunosuppressed patients
• Patients who refuse blood transfusions for religious or other reasons.

OPCAB is not recommended in the following patients:

• Patients with enlarged hearts
• Patients with valve disease
• Patients who require long grafts
• Patients with blockages extending into the heart muscle

OPCAB Surgical Procedure

The goal of Off-Pump Coronary Artery Bypass surgery is:

• To relieve symptoms of CAD
• Improve blood flow to the heart
• To lengthen the patient's life

Off -Pump Coronary Bypass surgery is performed by Cardiothoracic surgeons in the operating room with the patient under general anesthesia. The operation usually takes about 3 hours but may be longer depending on the number of bypasses to be done. During OPCAB, the patient is placed lying on their back on the operating table. The chest and graft area are shaved and scrubbed with antiseptic. You will be given a general anesthetic so you will be asleep and not feel any pain.

• Your surgeon will make a long incision down the middle of your chest bone (sternum). This is called a median sternotomy. Special instruments called retractors are used to spread the ribs apart so the surgeon can access the heart.
• At the same time, another surgeon will "harvest" (remove) a vessel from either your arm (radial artery) or leg (long saphenous vein) to be used as the graft. This may be done through a large "open" incision or endoscopically through a much smaller incision.
• Your surgeon may choose to use an artery in the chest called the internal thoracic artery. In this case you will not have a "graft site" incision on your arm or leg unless you are having multiple bypasses performed.
• With the heart beating, your surgeon will stabilize the heart muscle on either side of the blockage with a special device. This enables the surgeon to work on a small area with minimal movement but with the heart still beating and pumping blood throughout the body.
• If a leg or arm graft is used the surgeon then attaches one end of the graft with fine sutures to the Aorta.
• The other end of the graft is then attached to the coronary artery beyond the blockage. This enables the blood to "bypass" the blockage and flow freely to the heart muscle.
• If the internal thoracic artery is used, your surgeon will redirect the artery by detaching one end of it and reattaching it below the blockage on the coronary artery.
• Once your surgeon has completed the number of bypasses needed the surgeon will use wires to reattach the sternum and suture the incision closed, usually with dissolvable sutures.

Post Operative Guidelines

After OPCAB surgery you will be taken to the intensive care unit (ICU) for monitoring for 24 hours.

You will probably have a tube in your throat connected to a respirator for the first day to help you breathe. You will not be able to speak while the tube is in place.

You will have drain tubes in your chest to help drain blood and fluids.

You will likely spend 4-5 days in the hospital.

Common post-operative guidelines following Off-Pump Coronary Artery Bypass surgery include the following:

• You will need someone to drive you home after you are released from the hospital. You should not drive for 4-6 weeks after the surgery. If you drive commercially, you will usually have to wait 3 months.
• You will be given instructions on care of your incisions. Normally, you will be able to shower without restrictions.
• Expect significant fatigue for the first two weeks after your surgery. This is common and will improve gradually over the next month.
• Your surgeon will give you activity restrictions such as no heavy lifting or strenuous exercise for the first 4-6 weeks to allow the sternum to heal completely.
• You will usually be able to resume sexual activity after 3-4 weeks.
• You may be able to return to work in 6-8 weeks depending on the type of work you do.
• You will have soreness and bruising around the incision and graft sites for the first month or so. You may hear a clicking sound in the chest while the sternum is healing. You will probably have chest pain with sudden movement, coughing, or sneezing. Be assured this is usually musculoskeletal pain and not angina. Your doctor will prescribe pain medications for you to take at home.
• Your doctor will prescribe blood-thinning medicines to prevent blood clots. It is very important that you adhere to your prescribed medications to prevent blood clots from forming.
• It is common to feel depressed after heart surgery. Talk with your doctor, as treatment is available through medication or therapy.
• Sleep disturbances are commonly reported. Again, discuss your concerns with your doctor should you have problems sleeping.
• You will be referred to a cardiac rehabilitation program to educate and assist you with your recovery. This usually involves exercise, lifestyle modification, and monitoring.
• It is important to know abnormal symptoms to report: Contact your doctor immediately if you have a fever, chills, purulent drainage from incisions, redness, bleeding, irregular heart beat, chest pain, shortness of breath, weakness, or dizziness.

Risks & Complications

• As with any medical procedure there are potential risks involved. The decision to proceed with the procedure is made because the advantages outweigh the potential disadvantages.
• It is important that you are informed of these risks before the procedure takes place.

Most patients do not have complications after Off-Pump Coronary Artery Bypass surgery; however complications can occur and depend on what type of surgery your doctor performs as well as the patient's health status. (i.e. obese, diabetic, smoker, etc.)

Complications can be medical (general) or specific to OPCAB.

Medical complications include those of the anesthesia and your general well being. Almost any medical condition can occur so this list is not complete. Complications include:

• Allergic reaction to medications or dye
• Blood loss requiring transfusion with its low risk of disease transmission
• Heart attack, strokes, kidney failure, pneumonia, bladder infections
• Complications from nerve blocks such as infection or nerve damage
• Serious medical problems can lead to ongoing health concerns, prolonged hospitalization, or rarely death.

Specific complications for Off-Pump Coronary Artery Bypass surgery include:

• Heart Attack
• Stroke
• Bleeding
• Deep wound infection requiring IV antibiotics and possible surgical debridement.
• Arrhythmia (Irregular heart beat)
• Nerve damage causing weakness, neuropathy, or paralysis.
• Blood vessel damage requiring an operation for repair.
• Conversion to traditional CABG on emergency basis with need for CPB and its associated risks
• Vein graft occlusion or stenosis
• Recurrent Angina
• Blood clots
• Death (less than 3%)

Risk factors that can increase the chance of complications following Off-Pump Coronary Artery Bypass surgery include:

• Diabetes
• History of kidney disease
• Poor cardiac function
• Extensive heart disease
• Poor nutrition
• Smoking
• Obesity
• Age (over 60)
• Alcoholism
• Chronic Illness
• Steroid Use

Valvular Heart Disease

Valvular heart disease is a common heart condition caused by malfunctioning heart valves. There are 4 valves in the heart that function to keep blood moving in one direction. When a valve is diseased or abnormal and doesn't close completely, blood can back up instead of going forward. This is called regurgitation or "leaky valve". When a valve opening is too narrow, the heart has to work harder to pump the blood throughout the body. This narrowing of the valve opening is called stenosis. Valvular Heart Disease is a serious condition that causes the heart to work harder. If left untreated Valvular Heart Disease can lead to Congestive Heart Failure, Cardiomyopathy, and even death.

Many patients with Valvular Heart Disease can successfully control their symptoms with medications, however medications cannot cure diseased or abnormal heart valves.

In some cases, patients are unable to tolerate the side effects of the medications or do not respond to the medications and require further intervention. In other cases, the valves are so diseased or abnormal there is no other option except to repair or replace the valve.

Heart valve surgery may be an option for these patients. Traditionally the surgery has been performed through a long chest incision with the breastbone or sternum split and ribs spread apart. Minimally invasive techniques for repairing or replacing diseased or abnormal valves have been developed that require a much smaller incision with partial or no splitting of the breastbone.

Heart Valves

The main function of the heart valves is to regulate and prevent the backflow of the blood.

There are four important valves in the heart. Move your cursor over the labels to find out more.

Tricuspid Valve

The tricuspid valve regulates blood flow between the right atrium and the right ventricle.

It prevents the backflow of blood to the right atrium when the right ventricle pumps blood to the lungs.

Mitral Valve

The mitral valve regulates the blood flow between the left atriuma and the left ventricle.

It prevents the backflow of blood to the left atrium when the left ventricle pumps blood through the aorta to the rest of the body.

Pulmonary Valve

The pulmonary valve regulates the de--oxygenated blood from the right ventricle to the lungs for purification.

Aortic Valve

The aortic valve regulates the oxygenated blood pumped from the left ventricle to the rest of the body.

The left side of the heart has to work harder than the right side because it functions to pump blood to the entire body, not just to the lungs. Because the Mitral and Aortic valves regulate blood flow in the left side of the heart, these valves are the most commonly replaced valves accounting for 98% of all valve replacement surgeries.

What is Valvular Heart Disease?

Valvular Heart Disease is a condition where one or more valves in the heart do not function properly. There are four valves in the heart that open and close to keep blood flowing in one direction. Malfunctioning valves can cause blood to back up instead of moving forward in one direction. This is referred to as regurgitation. Some valves have stiffened and narrowed over time making it more difficult to pump blood through the narrowed opening. This is referred to as stenosis. These conditions cause the heart to try and pump harder to move the same amount of blood. Over time, this extra workload takes it toll on the heart weakening the heart muscle, a condition called Cardiomyopathy. Left untreated, Valvular Heart Disease will ultimately lead to heart failure.

Risk factors for Valvular Heart Disease include the following:

• Untreated strep throat that leads to Rheumatic fever
• Infection in the lining of the heart and valves called Infective Endocarditis
• Advancing age causing weakening of the valves or calcification of the valves
• Congenital heart disorders (occurring at birth)
• Coronary Artery Disease
• Myocardial Infarction or heart attack

Signs and Symptoms of Valvular Heart Disease may be mild, moderate, or severe and can include the following:

• Shortness of breath
• Swelling of lower extremities or abdomen
• Arrhythmia: fast or irregular heart beat
• Wet cough
• Palpitations
• Tiredness or lethargy
• Syncope or fainting
• Light-headed or faint
• Chest pain
• Blood clots
• No symptoms at all

A Cardiologist should evaluate all heart conditions for proper diagnosis and treatment.

Your Cardiologist will perform the following:

• Medical History
• Physical Examination

Diagnostic Studies may include some or all of the following:

• (EKG or ECG) Electrocardiogram
  EKG is a test to measure the electrical activity of the heart and provides your doctor with information about your heart rate, rhythm, size of the heart chambers and previous damage to the heart. It is non-invasive and painless and is performed by attaching electrodes to various parts of the body.
• Cardiac Catheterization:
  This is a surgical procedure performed by inserting a catheter into an artery in the arm or leg and advancing it into the heart. A dye is then injected and x-ray pictures are taken of the heart showing your doctor if any heart valves are damaged.
• Chest X-Ray:
  A form of electromagnetic radiation that is used to take pictures of bones. Non-invasive and painless, a chest x-ray can show signs of an enlarged heart.
• Echocardiogram:
  Echocardiogram is a test that uses sound waves to create a moving picture of the heart. The picture is much more detailed than x-ray images and involves no radiation exposure. These ultrasound images help identify abnormalities in the heart muscle and valves, and find any fluid that may surround the heart.

Management of Valvular Heart Disease depends on the following:

• Type of disease
• Severity of symptoms
• Underlying cause
• Your overall health

The goals of treatment for Valvular Heart Disease are:

• Decrease workload on the heart
• Restore normal heart rhythm
• Prevent blood clots and strokes

Conservative Management Includes:

• Lifestyle Modifications
• Medications

Lifestyle Modifications

Healthy life choices will improve your overall health and your heart health and can help you slow the progression of your heart disease. Some heart healthy choices include:

• Healthy Diet Choices-Eating a low fat, low salt, low cholesterol diet while avoiding excessive intake of alcohol and caffeine.
• Don't Smoke-If you do smoke, talk to your doctor about available options to help you quit. You will immediately lower your risk of heart disease as soon as you quit.
• Reduce stress through exercise- Increasing your physical activity is a great way to reduce stress, improve sleep, lose weight, and improve your overall sense of wellbeing. Always discuss with your doctor before beginning any new exercise program.
• Weight Loss-Being overweight puts extra strain on your heart. Discuss weight loss options with your doctor and follow his advice.

Medications

Along with life style modification for heart health, medications are needed to control symptoms of Valvular Heart Disease. More than one medication may be prescribed. Some common medications are listed on the left. Move your cursor over the medications to find out more.