CABG in Elderly: A challenge

An 85-year-old woman is brought to the emergency department of Indraprastha Apollo Hospitals by her family members with severe chest pain lasting for half an hour and radiating to the left shoulder. She was being treated for hypertension and diabetes for 15 years. The emergency department team at Indraprastha Apollo Hospital examines the patient and administers life-saving primary care. The ECG of the patient showed changes suggestive of a heart attack. The patient is then examined by the Cardiologist at Indraprastha Apollo Hospital. The patient is diagnosed with a heart attack. The Cardiologist performs an angiogram on the patient to study the blood vessels supplying the heart. The angiogram showed that three vessels supplying the heart were blocked. The Cardiothoracic Surgery team is then involved in the care of the patient. The patient is taken up for a Coronary Artery Bypass Graft (CABG) procedure. The multidisciplinary team including Cardiothoracic Surgeons, Cardiologists, Anesthetists and Cardiac nurses perform a 4 hour long surgery. During the surgery, a segment of a vein was removed from the leg of the patient and was used to bypass the blocked vessels in the heart. After the surgery, the patient was monitored in the Cardiac Post-Anaesthesia unit. Then the patient is moved to the normal ward room in the cardiac unit and discharged after 10 days post-surgery. There were no complications during the post-surgery period.

In the following month, an 80 year old woman was admitted with similar complaints at Indraprastha Apollo Hospitals. She was treated with CABG and discharged without any complications.

The heart muscles are supplied by several blood vessels. These vessels can become narrow or be blocked by fat deposits. The main reasons include smoking, obesity, high blood pressure, diabetes, high blood cholesterol, and absence of regular exercise. Blockage of these vessels cause damage to the heart muscles and this condition is called coronary artery disease or CAD. The prevalence of coronary artery disease increases with age. Elderly are more prone to blockage of multiple vessels and left main artery.

After the age of 80, diagnosing and treating CAD becomes difficult. Many patients may not complain of chest pain and may have a silent attack. In elderly patients, ECG usually shows abnormalities even at rest. Prompt recognition of the condition and medical therapy are required. CABG is a procedure done to restore the blood supply of the heart. This is an open heart procedure performed in 3 -4 hours under general anesthesia. The main aim of CABG is to prevent further heart attack and sudden death of the patient by re-directing the blood flow to the heart. In this surgery the blood flow to the heart muscles is restored via grafts. Grafts are sections of veins removed from other parts of the body and connected to the blocked vessels in the heart. The grafts usually taken are Saphenous vein and left internal mammary. The Saphenous vein is removed from the leg. The internal mammary artery is an artery which is present behind the sternum. During the surgery, the surgeon removes the vein which has to be used as a graft. Simultaneously, the chest is also opened to reveal the heart. Once the heart is opened, the heart is stopped and the patient is connected to the heart-lung bypass machine. Then the grafts are divided into 4 to 5 bypasses, one end of the graft is sutured above the blockage and the other end is sutured below the blockage. During the recovery phase, the patient is advised rest and life style modifications like diet control.

Cardiovascular disease is the number one cause of death in western countries. The incidence of CAD is increasing worldwide in the elderly patients. In the elderly, CABG is a difficult procedure. The incidence of heart failure after the surgery is also high. In western studies, 8 year survival rates were 53%.

Every patient admitted to Apollo hospitals with the coronary artery disease is initially managed by medical therapy and primary percutaneous intervention. However, revascularization procedures like coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) is done if mandatory. Additionally, the Cardiothoracic surgeons of Apollo Hospitals also perform off-pump CABG or beating heart surgery. These are minimally invasive surgeries that involve a small incision. In elderly it can result in a faster recovery. Apollo hospital also has a special team of cardiac nursing care unit who are dedicated to the patient during and after the surgery. They monitor wound care, chest pain, palpitations, and temperature changes.

CABG is a risky procedure in elderly patients. In the present case, we were able to save the patient’s life due to prompt diagnosis and management. Elderly patients recover fully after the surgery and are discharged with no further complications. Follow- up evaluation in both the above cases showed the normal functioning of the heart. The patients were able to resume the normal activities.