“The time has come,” my Surgeon said,
“To talk of many things:
Of drugs and drips and sternum pain,
Of CABGs and stings.
And why the heck it feels so bad
And whether hearts have strings.”
(Apologies to Lewis Carroll – Through the Looking Glass and What Alice Found There, 1872)
This was another difficult post to write. This time, it’s because I wasn’t really there!
I hope I’ve found a balance between:
- My experience vs theoretical technical stuff – I don’t want to lose you, my reader!
- Interesting vs “you’ve lost me”
Well here goes! This post is about the Big One, the CABG procedure.
Shaking all over
6:00 am of CABG Day. My husband was sitting beside the bed watching me wake up. It was very quiet on the ward. I had my last chlorhexidine shower and put on the surgical gown. My fingers trembled as I tried to tie it up.
- I was fighting my thoughts
- I was fighting my shakes
- I was fighting my emotions
- But most of all – I was fighting my fear
I felt like I was about to be sacrificed.
They gave me a muscle relaxant and other pre-operative drugs for sedation and to help with the procedure. I began to feel very peculiar, as if tired but not really. When I shut my eyes I saw psychedelic shapes and colours moving under my eyelids. I think I was babbling nonsense.
They wheeled me on a trolley along the corridor to the lifts. I remember seeing my husband standing on the other side as the doors slid shut. He looked worried.
The lift descended.
I was in a small pre-op room. Hello, there’s Dr S., my anaesthetist! It was so good to see his familiar face but he was in Official Mode now. I looked at the theatre nurse hoping for some reassurance; she was wearing a silly paper hat. Why do surgical people wear these? I felt it was most inappropriate at such a serious time.
The room was freezing. I was on a narrow, hard metal table. I don’t know whether it was sheer terror or the cold but I was shaking uncontrollably. Huge – jerky – wild – shaking.
Image courtesy of ponsulak at FreeDigitalPhotos.net
A Coronary Artery Bypass Graft (CABG) operation is serious major surgery and things can go wrong. I kept away from those aspects when I was preparing myself, and I shall not dwell on them here either.
Obviously, I was deeply unconscious during the operation, so I’m relying on my cardiothoracic surgeon’s actual notes to describe what happened.
Description of procedure
Left Internal Mammary Artery to Lateral Anterior Descending, Saphenous graft to first diagonal and second diagonal sequentially.
Um, sorry, what?
Left Internal Mammary Artery – This large blood vessel branches off another large artery (subclavian). The LIMA is described as the “gold standard” for use in a CABG. As a bonus, it is even quite resistant to atherosclerosis. As my surgeon told me,
I think God put the LIMA there for more than one reason. It’s like it was meant for this operation.
Lateral Anterior Descending – The LAD is a major artery that sits in a groove running in the front part the heart between the right and the left ventricles (the lower chambers). My blockage was at the top of this artery where it branched.
Saphenous vein – This blood vessel has the magnificent title of “great saphenous vein” because it’s the longest one in the body. It’s conveniently near the surface, making it accessible for harvesting. (Yes, I said “harvesting”).
First and second diagonals – These are branches of the LAD that run diagonally away from the LAD and towards the left edge in front of the heart. In my case, they were starved of blood flow due to the blockage above.
Mmm, that probably didn’t help – so here’s another translation:
A healthy unblocked artery (LIMA) was snipped in half then re-attached to a spot below the blocked artery (LAD). Next, part of a vein (saphenous) was cut out from my leg, attached to the healthy aorta then connected to the two diagonal blood vessels beneath the blocked (LAD) artery.
Make sense? I hope so.
Here’s my surgeon’s attempt to draw it. He admitted that writing and drawing are not his forté – but that’s fine. I’d rather he concentrates on heart surgery, not drawing.
How about this? My procedure was similar to a combination of these two images.
Yeah, I know – not that good either. Hey, don’t worry about it.
Just imagine a bit of snipping, reattaching and redirecting blood flow around the blockage. That’ll do.
Findings and actions
The surgeon described everything in detail, right down to the internal diameter of my blood vessels!
To avoid upsetting the squeamish, here’s a selection of verbs, phrases and nouns from the surgeon’s report. Just use your imagination – or if you’re brave, click the hyperlinks (I dare you).
|Cardioplegia||Inspected||Aorta was unclamped|
The heart was repositioned for exposure of the LAD
|Ligature clips||Median sternotomy||Once re-warming had been completed||
|Four figure of eight stainless steel wires||Retrieved|
Systemic hypothermia at 32˚C
Some medical phrases of which I am rather proud
“The left internal mammary artery was small in calibre, however, was of excellent quality and length and demonstrated vigorous sanguineous flow”.
In other words, my LIMA was really good!
“… achieved excellent myocardial cooling and diastolic arrest”.
My heart was cooled down and prevented from beating.
“This demonstrated excellent flow.”
Obviously, anything described as “excellent” sounds good to me.
“The patient was weaned from cardiopulmonary bypass without difficulty in sinus rhythm.”
My heart didn’t go crazy when they took me off the machine that did the work of my heart and lungs during the operation. I’d say that was excellent.
“Normal left and right ventricular function with excellent contractility without isotropic support.”
After the operation, my heart was beating fine on its own. Oh look, there’s that word “excellent” again.
The surgeon said my heart and blood vessels showed little sign of disease. Only that one pesky 98% blockage in the Widow Maker.
I am eternally grateful to everyone in that operating room, whom I never met nor had the chance to thank.
The Cardiac Surgery Team:
- The cardiothoracic surgeon (with bad drawing skills but nimble hands for surgery)
- Anonymous assisting surgeons
- Cardiac theatre nurses (with silly paper hats)
- Dr S., my wonderful anaesthetist
- The perfusionist (who runs the cardiopulmonary bypass machine)
- Anyone else I may have missed or forgotten
You all saved my life. I can never forget this.
Thank you from the depths of my CABG’d heart.
Questions, because I always ask them:
- To dwell or not to dwell? Yes, let’s be optimistic, but how much should we think about the bad aspects of what we are facing?
- Can you guess the internal diameter of my Lateral Anterior Descending artery?
Post your guess and I’ll tell you who the winner is next time.
Reading, because this you want to know more:
Simple Description, easy to read articles about CABG
These references below are intense, so if you read them you’ll impress me
This article reads like a shopping list of what’s needed to perform a CABG, then goes on to describe what to do like a Standard Operating Procedure (pardon the quality assurance related pun).
Lateral Anterior Descending artery (a nice little explanatory animation)
Left Internal Mammary Artery used for Lateral Anterior Descending in a Coronary Artery Bypass Graft
Comparison of the saphenous vein and the Left Internal Mammary Artery in CABG
Post-operative temporary epicardial pacing: When, how and why?