The Bypass. For Indians, this is a very familiar term. For generations, the Heart Bypass Surgery has been a principal treatment procedure for heart patients. Almost every family will have an aunt or a grandparent who has undergone the procedure, who sometimes proudly display the scars of surgery as a badge of survival.
Known as the Coronary Artery Bypass Grafting, or CABG, the bypass surgery is used to treat multiple blocks in the coronary artery - or the main blood vessel supplying the heart. Blocks in the vessel could severely limit blood flow, causing the heart muscle to sustain damage. If treatment - restoring of blood flow - is not immediately done, the patient could go into cardiac arrest, and die.
Known as Coronary Heart Disease, Indians are at particular risk for it. Some research shows that even as the risk of communicable diseases in India have fallen, the risk of non-communicable disease such as CHD diseases have grown, with cities like Chennai reporting the highest number of deaths due to the disease.
Prevalence of risk factors like diabetes, hypertension, smoking and pollution, obesity and physical inactivity, together with urbanization and change in lifestyle has exposed a larger number of Indians to the disease.
Thankfully, specialised treatments like the Coronary Bypass have allowed patients in India to survive the disease.
Surgery, till recently, was complicated and had many associated risks. Patients had to present stable conditions with no âco-morbidityâ - that is, no other diseases that could make surgery complicated. Further, the cost of such procedures, till recently, was very high, which meant only a certain section of the population could access it.
But under Dr. MM Yusufâs supervision, all that is changing. Dr. Yusuf, a senior Cardiac Surgeon at Apollo Hospitals in Chennai, is one of the pioneers of Minimally Invasive Coronary Artery Bypass Grafting.
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Minimally Invasive Coronary Artery Bypass Grafting: Smaller Cuts, Better Results
"When it comes to Minimally Invasive Cardiac Surgery - more than pioneers, we're one of the few centres who perform this in the country. There are only four or five centres in the country which do these surgeries routinely and we're among them," says Dr MM Yusuf. "In Tamil Nadu, we're the only centre," he adds.
The earlier CABG procedure involved making a large cut into the chest of the patient, to expose the heart. The centre of the chest cavity - protected by the rib cage - had to be cut open, to allow doctors to reach the heart, and its main blood vessels. Once there, the blocked vessel is identified and isolated, and an alternate pathway for blood to flow is created using a graft of artery from another part of the body. Blood flow is then restored to its maximum capacity to the heart.
Once doctors are assured that the heart is beating properly, they will then close the incision, and move the patient to recovery in the ICU.
However, with Minimally Invasive CABG, Dr. Yusuf avoids making a full cut, and instead makes a small incision between the ribs. "For bypass operations, it's either single, two vessels or all three vessels which are blocked. If it's a single or two vessel bypass, we make a single cut of two to three inches under the nipple. We then make a tiny hole which is used to insert the camera. The operation is performed with the guidance of this camera and a high definition monitor. A chest drain is inserted through this hole at the end of the operation. We do the entire CABG procedure through this 2 to 3 inch cut," says Dr. Yusuf.
This reduces the time taken for procedure to complete, which allows the patient to recover quickly, and reduces risk of contracting infections or complications. "With this procedure, the patient can go home on the second day after the surgery," Dr Yusuf says, listing out the advantages of a minimally invasive bypass. "There is hardly any blood loss, so there is no need for blood transfusion. There is also no pain," he says.
Hybrid Procedures, For Better Patient Outcomes
The procedures that Dr. Yusuf performs call for great coordination and team work between surgeons, anaesthesiologists, interventional cardiologists, cathlab technicians, nursing and support staff. Over years of working together and lots of practice, their routine can go off like clockwork, which ensures patients receive life-saving treatment with no risks, and in the shortest possible time.
Apollo is also now pioneering another procedure - a Hybrid CABG with Stents. "We're probably the only ones in the country who are currently doing this hybrid procedure."
The Hybrid procedure involves a combination of both Minimally Invasive CABG, and Percutaneous Coronary Intervention Techniques. The Cardiac surgeon will first perform a minimal cut and graft the bypass artery in one or two blocked arteries, and then transfer the patient to a cathlab for the PCI.
The PCI procedure involves using catheters (specialised wires) to reach the point of a block in the artery, and deploy a stent - a tube-like stainless mesh that will âcrushâ the block, and push it away from blood flow. The stent will then hold the artery wall up, allowing for free flow of blood.
âWhile minimally invasive bypass can be done for one or two blood vessels, the hybrid CABG and stent procedure is done if the patient has all three blood vessels blocked,â says Dr. Yusuf.
"If, say, on Monday I do the CABG procedure, on Tuesday, they're taken to the cathlab where they perform the stenting. The patient is then transferred to the coronary care unit for observation for 24 hours. And then, she is shifted to the ward on Wednesday and discharged home on Thursday.â
âHowever, patients will need to be carefully selected for such a procedure - which will depend on the nature of the blockages in the blood vessels, and function of the heart. If these factors are not favourable, we have to go for open heart surgery," cautions Dr. Yusuf.
Today, over 60% of adult cardiac patients can benefit from Minimally Invasive CABG, and Hybrid CABG procedures. Dr Yusuf says, "The number can go up once more doctors and more patients start accepting these procedures, and if the awareness goes up and the cost comes down."
All this translates to better patient survival rates, and better quality of life post-surgery. Minimal invasion means fewer complications, and shorter time to recover. Patients can return to their normal routine very soon, and look forward to a longer, better life.