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Quadruple bypass and mitral valve repair with 20% ejection fraction
I am a 47 year old male. I had a cardiac arrest in October 2009 (due to blocked left anterior descending (LAD) artery) and since then my ejection fraction became 20% (previously 45%, since MI in 2001), and my mitral valve also started to leak since october 2009 . I am now scheduled for a combined quadruple by-pass and mitral valve repair surgery on Jan 15. I have totally stopped smoking since October and had been recovering well through medicine for CHF and rehab. Here are my questions: should I have a combined surgery or should I have the by-pass by itself and then have a separate surgery for mitral valve? what are my prognosis for successful surgery? recovery?, and life after surgery? Is on-pump or off-pump surgery better (I am scheduled for on-pump)? Do the surgeons have control over how much clamp time is used for surgery? Is reduced clamp time better? How closely the surgery team monitors the temperature, and other electronics? Is there any thing a patient should or can request? Any other words of encouragement and advice or suggestions etc?
I think you are referring to the Da Vinci Robot? which is a fantastic state of the art piece of kit. They are far and few between in UK hospitals, due to their cost. However, they have one in the hospital which did my bypass. I was not seen as a good candidate because one of the grafts had to be sutured round the back of the heart. The Da Vinci Robot is only really ideal when all grafts are to the left side of the heart.
What is really amazing is the way it compensates for movement so quickly that it makes the heart look like it's standing still. As the camera focuses on the heart, a computer analyses the heart movement and the tools and camera are moved constantly to keep them the same distance from the heart at all times, making it seem like its standing still. When the chambers contract, the tools and camera move in, when the chambers relax, they move back out. They can also remove one end of the mammary arteries with this robot to use as grafts. I was blown away when they showed me.
Continuing with robots, the same hospital has a robot which belongs to a top surgeon there. The robot goes to his patients in different wards and he talks and listens to them through it. Sitting in his office, looking at notes, he never has to leave his desk. I'm not sure what to make of this, I think a personal visit shows more care. The surgeon believes flaunting technology gives patients more confidence. I suppose thats ok if you are a trekkie. I did see nurses complaining though, because it had a habit of nearly running them over.
What is really amazing is the way it compensates for movement so quickly that it makes the heart look like it's standing still. As the camera focuses on the heart, a computer analyses the heart movement and the tools and camera are moved constantly to keep them the same distance from the heart at all times, making it seem like its standing still. When the chambers contract, the tools and camera move in, when the chambers relax, they move back out. They can also remove one end of the mammary arteries with this robot to use as grafts. I was blown away when they showed me.
Continuing with robots, the same hospital has a robot which belongs to a top surgeon there. The robot goes to his patients in different wards and he talks and listens to them through it. Sitting in his office, looking at notes, he never has to leave his desk. I'm not sure what to make of this, I think a personal visit shows more care. The surgeon believes flaunting technology gives patients more confidence. I suppose thats ok if you are a trekkie. I did see nurses complaining though, because it had a habit of nearly running them over.
I have CAD and moderate to severe mitral valve regurgitation with normal EF. If I were to have an operation for the valve, the surgeon would do the bypass at the same time as I am told. I am surprised you're having an operation with such a low EF, and that may be a procedural consideration for the surgeon. You are relatively young and a full recovery would be expected, but there may be medical problem of restoring your left ventricle to normal functionality and that is the risk with a heart operation with low EF. There is a team of professionals to monitor vital signs and provide proper dosage of medication, etc.
MIDCAB....You have decided on CABG but the following may be of interest and that is off the pump and minimal invasion.: There is another procedure often called "quintessential" minimally invasive heart surgery, minimally invasive direct coronary artery bypass, or MIDCAB, follows the basic premise of conventional coronary artery bypass graft surgery (CABG), but in a truly minimally invasive fashion. Whereas CABG requires cardioplegia (arrest of contractions) to stop the heart, the use the heart lung machine for cardiopulmonary bypass, and a 30 cm. long, sternum-splitting incision, MIDCAB doesn't utilize the heart lung machine or cardioplegia and only uses a tiny incision that avoids splitting the sternum bone.
Your surgeon may not be qualified so the procedure is not offered. This procedure is more difficult than conventional bypass for two reasons. First, the surgeon must maneuver through an incision that it approximately one third (12 cm) of the size of the incision in conventional CABG (30cm). Secondly, the surgeon is operating on a beating heart, which means both movement and blood; two issues not present in conventional CABG. Therefore, this procedure requires much more skill and manual dexterity than conventional CABG
Information regarding the procedure you will have. The Conventional CABG is the gold standard in heart surgery for two main reasons. First, working on a non-beating heart allows for more efficient and more precise anastomosis. Second, and more importantly, CABG has been tried and tested making it widely accepted as the best heart surgery. As will all medical technologies, surgeons are reluctant to haphazardly switch from a procedure or a device with years of high success and proven reliability to a recently developed procedure or device which may look better intuitively and on paper but has not shown the same reliability and success.
However, CABG is not without complications and disadvantages:
Patients are in surgery and under anesthesia for around 6 hours consequently increasing post-operative intensive care treatment
The 30 cm., sternum-splitting incision is cosmetically displeasing and increases pain, discomfort, and hospitalization time for the patient.
Patients often require blood transfusions
Long surgery and hospital stays lead to high costs.
CABG often requires months for full recovery
In addition, cardiopulmonary bypass (the heart lung machine) is associated with a number of serious complications.
Fluid shifts in the body and depression of the patient's immune system.
Postoperative bleeding from inactivation of the blood clotting system as it passes over the artificial surfaces in the heart-lung machine.
Hypotension associated with heart-lung machine may cause renal failure and ischemia of the brain.
Recently, a number of strokes and neurological deficits, as many as 25,000 a year, have been linked to the use of the heart-lung machine.
Further problems with the Heart-Lung Machine
Several recent studies propose significant benefits of MIDCAB over CABG.
The procedure is performed in only two to three hours, compared to three to six hours for a traditional bypass.
The recovery time is dramatically reduced from months, to days or week.
Complications associated with the heart-lung machine are avoided.
There is a reduced need for blood transfusions, if any.
Due to less time under anesthesia, patients are moved out of intensive care more quickly.
Patients tend to experience less pain and discomfort than CABG patients.
The 10 cm. incision is cosmetically more acceptable than a 30 cm one.
Initial figures estimate up to 40% savings off the cost of conventional CABG.
A recent study showed a significantly higher quality of life for MIDCAB patients compared to CABG patients..
According to several studies, MIDCAB has shown a 90% effectiveness rate in worldwide studies and has provided substantial relief to approximately 95% of all patients undergoing the procedure.
There is off the pump without minimal invasion that would not have some of the advantages of MIDCAB.
MIDCAB....You have decided on CABG but the following may be of interest and that is off the pump and minimal invasion.: There is another procedure often called "quintessential" minimally invasive heart surgery, minimally invasive direct coronary artery bypass, or MIDCAB, follows the basic premise of conventional coronary artery bypass graft surgery (CABG), but in a truly minimally invasive fashion. Whereas CABG requires cardioplegia (arrest of contractions) to stop the heart, the use the heart lung machine for cardiopulmonary bypass, and a 30 cm. long, sternum-splitting incision, MIDCAB doesn't utilize the heart lung machine or cardioplegia and only uses a tiny incision that avoids splitting the sternum bone.
Your surgeon may not be qualified so the procedure is not offered. This procedure is more difficult than conventional bypass for two reasons. First, the surgeon must maneuver through an incision that it approximately one third (12 cm) of the size of the incision in conventional CABG (30cm). Secondly, the surgeon is operating on a beating heart, which means both movement and blood; two issues not present in conventional CABG. Therefore, this procedure requires much more skill and manual dexterity than conventional CABG
Information regarding the procedure you will have. The Conventional CABG is the gold standard in heart surgery for two main reasons. First, working on a non-beating heart allows for more efficient and more precise anastomosis. Second, and more importantly, CABG has been tried and tested making it widely accepted as the best heart surgery. As will all medical technologies, surgeons are reluctant to haphazardly switch from a procedure or a device with years of high success and proven reliability to a recently developed procedure or device which may look better intuitively and on paper but has not shown the same reliability and success.
However, CABG is not without complications and disadvantages:
Patients are in surgery and under anesthesia for around 6 hours consequently increasing post-operative intensive care treatment
The 30 cm., sternum-splitting incision is cosmetically displeasing and increases pain, discomfort, and hospitalization time for the patient.
Patients often require blood transfusions
Long surgery and hospital stays lead to high costs.
CABG often requires months for full recovery
In addition, cardiopulmonary bypass (the heart lung machine) is associated with a number of serious complications.
Fluid shifts in the body and depression of the patient's immune system.
Postoperative bleeding from inactivation of the blood clotting system as it passes over the artificial surfaces in the heart-lung machine.
Hypotension associated with heart-lung machine may cause renal failure and ischemia of the brain.
Recently, a number of strokes and neurological deficits, as many as 25,000 a year, have been linked to the use of the heart-lung machine.
Further problems with the Heart-Lung Machine
Several recent studies propose significant benefits of MIDCAB over CABG.
The procedure is performed in only two to three hours, compared to three to six hours for a traditional bypass.
The recovery time is dramatically reduced from months, to days or week.
Complications associated with the heart-lung machine are avoided.
There is a reduced need for blood transfusions, if any.
Due to less time under anesthesia, patients are moved out of intensive care more quickly.
Patients tend to experience less pain and discomfort than CABG patients.
The 10 cm. incision is cosmetically more acceptable than a 30 cm one.
Initial figures estimate up to 40% savings off the cost of conventional CABG.
A recent study showed a significantly higher quality of life for MIDCAB patients compared to CABG patients..
According to several studies, MIDCAB has shown a 90% effectiveness rate in worldwide studies and has provided substantial relief to approximately 95% of all patients undergoing the procedure.
There is off the pump without minimal invasion that would not have some of the advantages of MIDCAB.
I had a triple bypass in sept 07 and there were no complications, those are rare. With regards to your quality of life, have they said anything about permanent heart muscle damage?
You should have both procedures done together if the surgeon is willing. The trauma of such surgery to the body is enough to endure once, let alone twice. It is also important to have the valve sorted so the heart can recover more easily.
I can only give one piece of practical advice to you for a more successful long term solution. Ask the surgeon if he can use both internal mammary arteries from your chest and just two veins. Arteries last so much longer because they are much stronger. Ask him to use the Lima and the Rima if possible. He will check if they have a good flow during surgery, if they do, he will then use them. The biggest problem with bypasses is veins closing up due to their weakness. You can take a bit of control with your surgeon, its your body and your life. Ask him to put the arteries in the worst blocked areas because this is where you want the good long lasting feeds. Ask him to draw a diagram of the artery and show you where the blockages are and you can see the best place for them.
You should have both procedures done together if the surgeon is willing. The trauma of such surgery to the body is enough to endure once, let alone twice. It is also important to have the valve sorted so the heart can recover more easily.
I can only give one piece of practical advice to you for a more successful long term solution. Ask the surgeon if he can use both internal mammary arteries from your chest and just two veins. Arteries last so much longer because they are much stronger. Ask him to use the Lima and the Rima if possible. He will check if they have a good flow during surgery, if they do, he will then use them. The biggest problem with bypasses is veins closing up due to their weakness. You can take a bit of control with your surgeon, its your body and your life. Ask him to put the arteries in the worst blocked areas because this is where you want the good long lasting feeds. Ask him to draw a diagram of the artery and show you where the blockages are and you can see the best place for them.
It is thought generally by some research that the quality of the grafts performed off pump are not as good as on pump. Apart from this there really is no difference. Personally, I like the idea of being on a pump ready for any complications. Time is of the essence in an emergency.
Here is something to read
http://www.transonic.com/abstract.php?ReprintDataID=7214&fromlist=1
a snippet from another report....
Methods and Results— In a multicenter trial, 281 patients (mean age 61 years, SD 9 years) were randomly assigned to off-pump or on-pump CABG. In-hospital results and cardiac outcome and quality of life after 1 month are presented. Cardiac outcome was defined as survival free of stroke, myocardial infarction, and coronary reintervention. The mean numbers of distal anastomoses per patient were 2.4 (SD 1.0) and 2.6 (SD 1.1) in the off-pump and on-pump groups, respectively. Completeness of revascularization was similar in both groups. Blood products were needed during 3% of the off-pump procedures and 13% of the on-pump procedures (P<0.01). Release of creatine kinase muscle-brain isoenzyme was 41% less in the off-pump group (P<0.01). Otherwise, no differences in complications were found postoperatively. Off-pump patients were discharged 1 day earlier. At 1 month, operative mortality was zero in both groups, and quality of life had improved similarly. In both groups, 4% of the patients had recurrent angina. The proportions of patients surviving free of cardiovascular events were 93.0% in the off-pump group and 94.2% in the on-pump group (P=0.66).
Here is something to read
http://www.transonic.com/abstract.php?ReprintDataID=7214&fromlist=1
a snippet from another report....
Methods and Results— In a multicenter trial, 281 patients (mean age 61 years, SD 9 years) were randomly assigned to off-pump or on-pump CABG. In-hospital results and cardiac outcome and quality of life after 1 month are presented. Cardiac outcome was defined as survival free of stroke, myocardial infarction, and coronary reintervention. The mean numbers of distal anastomoses per patient were 2.4 (SD 1.0) and 2.6 (SD 1.1) in the off-pump and on-pump groups, respectively. Completeness of revascularization was similar in both groups. Blood products were needed during 3% of the off-pump procedures and 13% of the on-pump procedures (P<0.01). Release of creatine kinase muscle-brain isoenzyme was 41% less in the off-pump group (P<0.01). Otherwise, no differences in complications were found postoperatively. Off-pump patients were discharged 1 day earlier. At 1 month, operative mortality was zero in both groups, and quality of life had improved similarly. In both groups, 4% of the patients had recurrent angina. The proportions of patients surviving free of cardiovascular events were 93.0% in the off-pump group and 94.2% in the on-pump group (P=0.66).
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Sorry to hear of your problems. You ask many serious questions that I don't know if the forum is qualified to answer, especially when it comes to recommending one treatment over another, plus we would only be guessing on your prognosis. Have you tried to post on the expert forum and ask the doctor?
Jon
Jon
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