In July 2023 I had the chance to participate in the Standing Committee on Professional Exchange Center for Indonesian Medical Student Activities (SCOPE CIMSA) professional exchange program at Mater Dei Hospital in Malta, more specifically in the cardiothoracic surgery department. In this department, I was fortunate enough to observe many surgeries and do patient care. One of the surgeries was coronary artery bypass grafting (CABG)
Coronary artery bypass grafting (CABG) is a crucial surgical intervention. CABG entails the utilization of harvested venous or arterial conduits to bypass atheromatous obstructions within the patient’s coronary arteries. By creating this bypass, the blood supply can be reinstated to the ischemic myocardium, restoring both its function and viability while alleviating anginal symptoms. CABG procedures can take two primary forms: on-pump and off-pump. The distinction lies in the utilization of a cardiopulmonary bypass circuit and the choice to arrest or not arrest the heart during surgery. Commonly employed conduits for these grafts include the left internal mammary artery (LIMA) and saphenous vein grafts (SVG) sourced from the lower extremities. Furthermore, the right internal mammary artery (RIMA), radial artery, and gastroepiploic artery stand as potential additional conduits for transplantation.
One case that I saw was Mr. X, a 62-year-old resident of Sliema, Malta, whose occupation is that of a Glass Blower. Examination on the 5th of July 2023 Shows significant details. The patient’s chief complaint revolves around radiating chest pain that has intensified over the preceding three days. This discomfort extends beyond the chest to involve the shoulder and abdomen. Mr. X also bears a history of controlled hypertension. His past medical record reveals recurring chest pain episodes over the past four years. Furthermore, there’s a familial background of ischemic disease, and notably, an angiogram conducted in 2020 exhibited no abnormalities.
These observations led us to Mater Dei Hospital of the University of Malta, where the patient underwent evaluation from the 3rd to the 28th of July 2023. Physical examination results included a blood pressure reading of 130/90 mmHg, a heart rate of 90 beats per minute, and a body temperature of 36.7 degrees Celsius. No ascites were noted. A new angiography uncovered a lesion in the left arteriole ascending artery (LAD).
Subsequently, the patient embarked on a meticulously planned treatment regimen. This encompassed antibiotic prophylaxis before surgery, followed by the intricate Coronary Artery Bypass Graft Surgery (CABG). Central line anesthesia was administered via the jugular vein, affording optimal comfort. The procedure entailed thoracic incision and sternotomy with retractor placement, facilitating access to the critical surgical site. To provide a stable field, cardiopulmonary bypass was introduced, momentarily resting the heart’s activity. Harvesting of the saphenous vein from the leg was executed seamlessly. Following this, a meticulous incision on the thorax and sternotomy allowed for the surgical approach. The grafting process involved both the saphenous vein and the internal mammary artery, meticulously securing reestablished blood flow. The cardioplegia washout protocol was executed to ensure appropriate heart function. Rigorous scrutiny was then applied to verify the integrity of both grafts, with no leaks detected. Subsequently, the chest was securely closed using a sternal wire, concluding the procedure.
After the procedure, postoperative care treatment is to maintain blood pressure and make sure that there is no complication and that the heart works by itself with minimal abnormalities. After 1 week patient is usually asked to return to do a wound check and suture and staple removal. INR of the patient is also checked. In 4 weeks’ time, the patient checked regularly their blood pressure and saw if there were complications such as pericarditis. After six weeks the patient can undergo a cardiac rehabilitation program.
This case serves as a testament to the efficacy of CABG in mitigating the debilitating effects of coronary artery disease, offering patients like Mr. X a renewed lease on life and improved cardiac function. Moreover, this surgery also allowed me to see firsthand the complexity and sophistication that goes into a CABG surgery.
Bachar, Bradlee J., and Biagio Manna. “Coronary Artery Bypass Graft.” PubMed, StatPearls Publishing, 2020, www.ncbi.nlm.nih.gov/books/NBK507836/.
de Waard, Dominique, et al. “Management of Patients after Coronary Artery Bypass Grafting Surgery: A Guide for Primary Care Practitioners.” Canadian Medical Association Journal, vol. 193, no. 19, 9 May 2021, pp. E689–E694, https://doi.org/10.1503/cmaj.191108.
By: Gabriel Damarwibawa Setianto, FK UNAIR