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Coronary artery bypass surgery

Continuing our series, cardiothoracic surgeon Professor John Pepper describes the care patients may need after a CABG

Continuing our series, cardiothoracic surgeon Professor John Pepper describes the care patients may need after a CABG

Coronary artery bypass surgery is a major operation, but it is relatively safe with a 30 day mortality of less than 2%.

By three months, approximately 90% of patients are back to normal activities. When patients leave hospital on the fifth to seventh post-operative day, they will have been walking on the flat for at least 100m and will have climbed one flight of stairs. They do not need nursing care, but they do need someone around the house for at least the first week to boost morale and help with household tasks.

In the first six weeks, patients should be aiming to walk for 20-30 minutes twice a day with a rest at midday and to be in bed by 10pm. Some patients develop short periods of anxiety and mild depression lasting one day or even as little as a few hours, which usually resolve spontaneously. The sternal wound is relatively comfortable because it is splinted by bone, but there is stiffness in the pectoralis major muscles, which rapidly improves, usually within the first six weeks, but occasionally lasts for eight to nine weeks.

This is improved by gentle swimming in the second six weeks of the three-month convalescence period.Most cardiac surgical units have a helpline run by experienced nurses on the surgical ward and patients should be encouraged to use this.

During the second six weeks, the patient should be able to walk up to one mile. The patient will have been reviewed in outpatients and is now allowed to drive a car, and encouraged to swim and ride a bicycle. This is the optimal time to join a local cardiac rehabilitation course which many find reassuring as it enables them to find their own pace. They can now take a short flight of less than five hours. My advice is to dissuade patients from returning to work until they reach the three-month mark.

Brain damage is a major concern to the patient and is part of the informed consent process. There are three types of damage:

• stroke with an incidence of less than 1% under age 75 but steadily rising thereafter
• delirium, which is fortunately uncommon at less than 1%
• neuropsychological injury, which occurs in up to 60% of patients but resolves by eight weeks in most cases, leaving 5-10% permanently impaired. The more intelligent the patient, the more evident the disability.

Other complications occur in one-third of patients and the most common are:
• atrial fibrillation
• pleural effusions
• leg wound infections.

Atrial fibrillation is most likely to occur in the first three to five days, and so the rate should be controlled by the time the patient arrives home or the rhythm may have reverted to sinus. My own policy is to discharge patients on a small dose of ß-blocker if they are in sinus rhythm, but atrial fibrillation is easily controlled by amiodarone, which can be stopped at six weeks in most patients.

Pleural effusions may develop even though the chest radiograph was clear at discharge. This should be picked up at the six-week outpatient visit and usually responds well to a simple pleural aspiration. If missed, the problem becomes complicated with folded lung and eventually a cortex requiring decortication. It is a common cause of increasing breathlessness in the first three months after surgery.

At least 50% of patients undergoing coronary artery surgery are diabetic, and so leg wound infections are common. They eventually respond to conservative treatment. Because of this, we and others are developing minimally invasive endoscopic methods of vein harvest. In endoscopic vein harvest one or two small incisions are made in the leg, through which an endoscope is passed and the vein harvested. The evidence so far is that the quality of the vein is as good, but the patient is not troubled by a long incision in the leg which often takes time to heal completely.

By contrast, the sternal wound and forearm wound, used for harvest of the radial artery, usually heal without a problem. Sternal wound dehiscence occurs in less than 1% of patients, but if it is serious and deep can carry a mortality of up to 40%. There should be a very low threshold for referring sternal wound problems back to the surgical unit. Deep infection in the mediastinum typically presents late and is difficult to diagnose clinically, but the hallmark symptom is continued retrosternal chest pain beyond six weeks. Such patients need urgent investigation.

Over the past 10 years there has been a growing enthusiasm for off-pump coronary artery surgery, which involves surgery without a heart lung bypass machine. This was motivated by a desire to prevent the inflammatory complications of the extracorporeal circuit. Overall in the UK, the adoption of this technique has been less than 20% but in some units and for some surgeons it is the preferred procedure for all coronary artery operations. The dose of heparin used in off-pump operations is usually less than on-pump and this results in a higher incidence of thromboembolism postoperatively, a complication that needs to be considered, especially as these patients tend to be discharged earlier.

Coronary artery surgery restores most patients to excellent health and provides a watershed in their lives to concentrate their mind on reducing their risk factors.

Professor John Pepper is professor of cardiothoracic surgery at the Royal Brompton and Harefield NHS Trust
Competing interests
None declared

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