With the incidence of cardiovascular disease going up, more and more people are having their thoraces sawed open-less to expose the love that hypothetically lies inside than to address possibly fatal health problems. But following a successful open-heart surgery, they may very well profess love or at least gratefulness for having been given a new lease on life.
One of the more commonly done cardiac procedures is coronary artery bypass grafting. Initially performed in the 1960s, the procedure has been used in patients with severely restricted coronary artery blood flow. Usually related to unhealthy lifestyle choices-what Dr. Ramon Abarquez famously called SEX, or Smoking, unhealthy Eating, and lack of eXercise-the impairment of the coronary arteries results from atherosclerosis, or the buildup and calcification of lipids and other substances in the blood vessel wall.
Over time the arteries may be severely narrowed if not totally clogged, which means not enough blood reaches the heart. This may lead to angina, or a myocardial infarction, or even death.
In a manner of speaking, coronary artery bypass grafting is the provision of alternate routes through which blood may reach the heart and other parts of the body. And depending on the number of "heavy traffic sites," the alternate routes may be taken from the great saphenous vein or either of the internal mammary arteries.
The harvest of the saphenous vein usually involves cutting open the portion of the leg directly covering the needed vein. And so the number of grafts to be done translates to the length of saphenous vein to be excised and also the length of leg incision. This leads to added pain for the bypass patient, opens up the possibility of complications such as infection and swelling, and delays mobility. With the trend in surgery progressively leading to developments of minimally invasive methods, the 1990s saw the development of endovein harvest, which virtually eliminates these risks.
Dr. Jorge Garcia, one of the leading figures in cardiac surgery both here and abroad and also medical director of the Asian Hospital and Medical Center, says endovein harvest is fairly simple. A small incision is made near the knee, and a vasoview instrument equipped with a microcamera is inserted to identify, isolate, and cut the needed length of vein. "It takes a little bit longer-maybe 10 minutes longer than the usual-but it's really worth it," he says.
Dr. Garcia says that practically anybody may submit to endovein harvest. "Occasionally, when the vein is very superficial, it's probably best to [do it the traditional way]," he qualifies. So far over 50 patients have benefited from this procedure, which is as yet only offered at the AHMC, and hardly any problem arose from the procedure.
As for the grafting itself, one may choose the traditional method of bypass grafting, which involves stopping the heart and hooking it up to a heart and lung machine; or off-pump coronary artery bypass (OPCAB), which does not involve cardioplegia.
Dr. Garcia, together with Dr. Joseph Barril, says that not everyone is qualified to submit to OPCAB. Most American institutions, Dr. Garcia says, do the procedure in only 30 percent of patients-at the AHMC, more than half of the cases underwent OPCAB.
He explains: "For example, you have an octogenarian who has other medical problems-if you can do it with the heart beating, that makes the operation 10 times safer for the patient. No question about that. On the other hand if you have another patient, where the block is so severe and very extensive, trying to do it with the beating heart technique is a joke."
Among the conditions in which OPCAB may not be suitable are extremely poor ventricular function, concomitant valvular disease, cardiac arrythmias, or unsuitable coronary anatomy (JD Fonger, 2000).
Dr. Barril says that in OPCAB, the area of the heart in which the harvested vein will be attached is stabilized with the use of special mechanical devices such as the "octopus" and the "starfish." During anastomosis blood flow in that region of the heart is temporarily impeded with the use of snares.
"You can do harm to a patient trying to do it with the OPCAB technique if they are not good candidates for it," says Dr. Garcia. "On the other hand you can do harm too trying to do the standard technique if there are reasons that will increase the complications. Using the heart and lung machine can be traumatic to the patient."
For Dr. Garcia, who is one of the pioneers of the procedure, among the benefits of OPCAB are less trauma to the patient, less blood loss and
therefore smaller need for transfusion, decreased hospital costs (resulting from shorter hospital stay and fewer medications), and a smaller possibility of succumbing to stroke.
Dr. Barril says that although the recovery of patients who have undergone OPCAB takes about six weeks, they usually are ready for discharge by the third or fourth day, and are only asked to return to the hospital for routine checkups.
Some patients, over time, may require reoperative bypass grafting. Dr. Barril says that if the source of the graft is either of the internal mammary arteries, higher than 90 percent-some sources say it could go as high as 97 percent-remain patent even after 10 years. Meanwhile, if the graft comes from the saphenous vein, the possibility of revascularization is higher. This is because they have a greater risk for atherosclerotic degeneration. To avoid this problem, or at least significantly minimize the risk of clogging, Dr. Barril says that patients are usually prescribed anticoagulants such as clopidogrel (Plavix) and aspirin.
Also, lifestyle modification helps improve a bypass patient's quality of life. Making necessary adjustments in one's diet, physical activity, and cessation of cigarette smoking would be beneficial: as the cliché goes, not only does it add more years to one's life, but adds more life to one's years.
Three things these photographs don't show: the time of the day (about seven in the morning December last year when MEDICAL OBSERVER was given the front seat inside the operating theater), the piped in music (an endless stream of old standards) with which Dr. Joseph Barril occasionally sings along, and the photographer (MEDICAL OBSERVER official lensman Boaner Medina). World-renowned cardiac surgeon Dr. Jorge Garcia and his team at the Asian Hospital and Medical Center are performing endovein harvest, which at this time is only done at AHMC, and a conventional bypass surgery.
