Operations for coronary heart disease. The procedure for surgical treatment of coronary artery disease, in what cases is surgery indicated? A patient with coronary heart disease underwent surgery

Definition of IHD.

Coronary heart disease, as defined by the WHO commission, is an acute or chronic dysfunction resulting from an absolute or relative decrease in the supply of arterial blood to the myocardium. Such dysfunction is most often associated with a pathological process in the coronary artery system.

Coronary insufficiency syndrome was first described in England by Heberden in 1768, who called it “angina pectoris”; 20 years later his compatriots Jenner and Parry explained chest pain with angina pectoris as “ossification of the coronary vessels”. In Russia V.P. Obraztsov and N.D. Strazhesko \1909\ described the clinical picture of acute myocardial infarction. Subsequent observations showed that angina pectoris and myocardial infarction are different stages of the same disease - coronary heart disease, which is based on coronary artery insufficiency, most often caused by atherosclerosis.

IHD is now so common and causes so many deaths that it is called an epidemic disease. Atherosclerosis of the coronary arteries is the leading cause of death in the adult population, especially in highly developed countries. Considering the trend towards “rejuvenation” of atherosclerosis, the problem of treating IHD is acquiring social significance, since this disease affects that segment of the population that ensures the scientific, technical and financial progress of most countries.

For a long time, the treatment of ischemic heart disease was considered a therapeutic problem, and indeed, the development of new drugs that significantly improve coronary blood flow and reduce the myocardial oxygen demand, which is the basis of the tactics of conservative treatment of ischemic heart disease, has improved the quality of life of many patients. It should be noted that the success of therapeutic treatment of coronary heart disease depends on the range of drugs used, but most of them are expensive, and the patient is forced to take them constantly for many years, and this also becomes an economic problem. However, with stenotic, and especially occlusive lesions of the coronary arteries, conservative treatment is ineffective. According to the famous English resuscitator Mackintosh \1976\, with conservative treatment of coronary artery disease, the seven-year survival rate of patients with stenosis of 1 coronary artery was 78%, stenosis of 2 coronary arteries - 51.5%, if there is stenosis of 2 coronary arteries with stenosis of the interventricular or circumflex branch, survival is only 37.0%.

The Heart Institute Cleveland, USA, in 1985 published statistics on the costs of the US Department of Health for conservative treatment of coronary artery disease, comparing them with cost items for cancer. The costs of medicines, hospital needs, losses to industry, disability costs and funeral costs were taken into account. It turned out that the amount of expenses for treatment of coronary artery disease was 3 times higher than the costs for cancer.

Thus, the need to assist these patients from a surgical perspective is clear.

Etiopathogenesis of IHD.

The cause of IHD in most patients is progressive atherosclerosis of the coronary arteries, this is confirmed by studies of pathologists who detect stenotic atherosclerosis of the coronary arteries in 92 - 96.8% of patients who died from myocardial infarction.

However, the role of disruption of coronary atherosclerosis in the pathogenesis of coronary artery disease is ambiguous and should be considered as a background process that can disrupt the functionality of the coronary system in relation to its adaptation to changing modes of heart function \ MFR at rest 4 - 5 l/min., in a sprinter at the finish line up to 40 l/min.. Speaking about the role of functional factors in the pathogenesis of myocardial infarction, we usually mean spasm of the coronary arteries, which changes the ability to regulate blood flow in the myocardium and leads to pronounced metabolic abnormalities, the production of catecholamines, which increase the myocardial oxygen demand. Thus, even with unchanged blood flow in the coronary vessels, acute myocardial hypoxia can occur.

Risk factors for the development of coronary artery disease:

age and gender \men over 40 years old\;
burdened heredity;
limited physical activity;
hypertonic disease;
obesity;
smoking;
chronic infections;

The clinical picture of angina pectoris and acute infarction was examined in detail at the departments of therapeutic profile; we will be interested in the problems of anatomy, diagnosis and surgical directions in the treatment of coronary artery disease.

Blood supply system of the heart.

1. Coronary artery system

right coronary artery – has 3 branches or segments;
left coronary artery – has 7 branches or segments;

2. Type of blood supply

left \optimal\;
right \most dangerous\;
balanced \moderately dangerous\;

When admitted to the carrier aviation department at the Higher Air Force Academy - West Point, USA, officers undergo coronary angiography to determine the condition of the coronary arteries and the type of blood supply. Only pilots with the left type of blood circulation are accepted, which ensures the best blood flow in the myocardium during stressful situations.

3. Collateral blood supply to the heart

from small branches supplying blood to the wall of the aorta,

lung tissue, bronchial branches;

from the pericardial arteries;
directly from the chambers of the heart;

Thus, it is possible to improve the blood supply to the heart only through direct revascularization of the coronary arteries or increasing collateral blood flow.

Diagnosis of coronary artery disease in a surgical clinic is based mainly on the use of instrumental research methods and analysis of general clinical data.

Instrumental research methods

Ultrasound of the pericardium and heart chambers\areas of akinesia, aneurysmal dilatations\

MR imaging of cardiac chambers in combination with a vascular program;
Ventriculography \assessment of myocardial contractility, akinesia zone\
Selective angiography \ when refractory to conservative treatment

treatment methods to assess blood flow disorders; rhythm disturbances not associated with valve pathology; determination of shunt patency after direct revascularization; acute myocardial infarction\

A clear understanding of the location of the lesion, the degree of narrowing and the condition of the peripheral bed of the coronary arteries allows planning myocardial revascularization operations.

Surgical treatment of ischemic heart disease.

The lack of sufficiently effective methods of conservative treatment of coronary sclerosis necessitates the development of various methods of surgical treatment of this disease. The advent of artificial circulation and coronary angiography played a major role in the development of various revascularization methods. At present, there is no doubt that for severe stenotic and occlusive lesions of the arteries, conservative therapy is ineffective. Surgical treatment is indicated to create new sources of myocardial revascularization. All surgical methods are divided into indirect and direct myocardial revascularization.

Indirect methods of revascularization.

They arose at the dawn of coronary surgery and were associated with the lack of artificial circulation capable of protecting the body and myocardium from ischemia. At the same time, a number of techniques are still used today when it is impossible for some reason to carry out direct revascularization or in order to prepare for planned coronary artery bypass surgery. The first operations were aimed at eliminating pain impulses, reducing basal metabolism or fixing organs and tissues rich in blood vessels and collaterals to the myocardium.

Jonesco (1916), Hoffer (1923), etc. – cervicothoracic sympathectomy

Blumgart, Levine (1933) and others – thyroidectomy

O. Shaugnessi (1936), P.I. Tofilo (1955), Kay (1954) and others sutured the omentum, rectus abdominis muscle, pectoralis major muscle, jejunal loop, stomach, diaphragmatic flap, spleen and lung tissue to the heart to enhance circumferential circulation.

Hudson (1932), Beck (1935), Thompson (1935) - used notches on the pericardium, its scarification and the introduction of talc into the pericardial cavity to create artificial pericarditis and indirectly improve blood circulation.

Fieschi in 1939 proposed ligation of the internal mammary artery on both sides to increase blood flow along the aa. pericardiophrenica, supplying the pericardium and myocardium.

Weinberg in 1946 recommended performing “tunnelization” in the thickness of the wall of the left and, if possible, the right ventricle with implantation of both internal mammary arteries into the tunnels. This operation was used for quite a long time in Europe and the USA as an alternative to the first attempts at coronary artery bypass grafting \ Heart Institute, Cleveland 1971 - 3000 operations were performed with 8.5% mortality \.

Mouse \Tomsk, 1980\ - creation of artificial exoendopericarditis without thoracotomy and pericardiotomy, fenestration of the chest and external treatment of the mediastinum with talc, used by the author when coronary artery bypass grafting is impossible due to diffuse damage to the coronary arteries.

Method of laser fenestration of the myocardium (1982 - 1985 Israel) - creation of a huge number of microholes \diameter 18 - 24 mmk\ in the thickness of the myocardium in the area of the wall of the left ventricle after catheterization of the left ventricle through the interventricular septum, then passing the light guide and connecting the laser - blood flows directly into the heart muscle, the method is used independently and as a method of preparation for coronary artery bypass surgery.

Direct methods of revascularization.

There are two main types of operations currently used - the application of a coronary artery bypass graft with an autologous vein or prosthesis, bypassing the affected area under conditions of artificial circulation \ CPB \ with cardioplegia and mammary coronary bypass surgery, which can be performed without CP.

Bailey (1957), Senning (1962), Effler (1964) - direct endarterectomy from the mouth of the coronary arteries followed by autovenous grafting - was not widely used due to the high mortality rate due to intraoperative myocardial infarction due to the lack of high-quality coronary angiography.

Sabiston (1962) – Coronary artery bypass grafting with autologous vein – unsuccessful, death on the 2nd day after surgery due to stroke

Michael de Baiki (1964), Favoloro (1967) – Coronary artery bypass grafting with a prosthesis and an autovenous vein with a successful outcome under IR conditions.

M.D. Knyazev (1971), V.I. Burakovsky, A.V. Pokrovsky (1971) - the first coronary artery bypass grafting in Russia with a successful outcome, performed at the Institute of Surgery named after. A.N.Bakulev under IR conditions.

V.I. Kolesov (1964) – mammary coronary bypass surgery under endotracheal anesthesia at the I LMI named after. acad. I.P. Pavlova

Postoperative mortality after CABG according to summary statistics (USA, Germany, Baltic countries, Russia) ranges from 2 to 11.2% and depends on the duration of the operation, the condition of the myocardium and the number of bypasses applied.

In the special risk group - operations against the background of acute myocardial infarction, mortality increases to 32 - 52% \ Review of the Heart Institute, Cleveland. 1980, V.I. Burakovsky 1997\.

Angioplasty.

In addition to the described revascularization methods for coronary artery disease, the method of angioplasty or balloon dilatation of the lumen of the coronary artery with vascular thrombolysis or stenting / installation of a metal prosthetic frame inside the lumen of the vessel is used (Grunzig, 1977). This method is used both as an independent method of treatment and as preparation for CABG. A positive effect is achieved in 65% of cases.

Damage to the coronary arteries of the heart is one of the manifestations of general atherosclerosis and leads to insufficient blood supply to the heart muscle (myocardium). Currently, the number of patients suffering from coronary heart disease (CHD) is constantly increasing and it, rightfully considered the “plague of the twentieth century,” claims the lives of millions of people every year.

For decades, therapists and cardiologists have been trying to find a way to combat this disease, searching for drugs, and developing methods to widen the coronary arteries (angioplasty). And only with the introduction of the surgical method of treating coronary artery disease did a real possibility of radical and adequate treatment of this disease arise. The method of coronary bypass surgery (direct myocardial revascularization method) has repeatedly confirmed its high value during its existence for 40 years. And if just a few years ago, the risk of surgery remained quite high, then thanks to the latest advances in cardiac surgery, it has been reduced to a minimum. This obvious progress is primarily associated with the emergence in the arsenal of surgeons of the method of minimally invasive direct myocardial revascularization.

The undeniable achievements of cardiac surgery, cardiology, anesthesiology and resuscitation have made it possible to look optimistically into the future of treatment of coronary artery disease.

The heart and its coronary arteries.

The main function of the heart is pumping; by ejecting blood from its cavities, the heart ensures the delivery of oxygen-enriched blood to all organs and tissues of our body.

The heart is a muscular hollow organ, physiologically divided into two sections - right and left. The right section, right atrium and right ventricle belong to the pulmonary circulation, while the left section, which also consists of the left atrium and left ventricle, belongs to the systemic circulation.

Despite this “frivolous” division of the departments of the heart into “large” and “small”, this does not affect the significance of these departments in any way - both of them have vital importance. The right parts of the heart, namely the right atrium, receives blood flowing from the organs, that is, already exhausted and poor in oxygen, then this blood enters the right ventricle, and from there through the pulmonary trunk into the lungs, where gas exchange occurs as a result of which the blood is enriched with oxygen . This blood enters the left atrium, then into the left ventricle, and from it through the aorta it is “thrown out” into the systemic circulation, carrying the oxygen necessary for every cell of our body.

But to perform this “titanic” work, the heart also needs oxygenated blood. And it is the coronary arteries of the heart, whose diameter does not exceed 2.5 mm and are the only way to deliver blood to the heart muscle. In this regard, there is no need to talk about the importance of the coronary arteries.

Causes of development of ischemic heart disease.

Despite this importance, the coronary arteries do not escape the fate of all other structures of our body from periodically failing. But it’s really not fair that every piece of lard, every eclair eaten or every piece of “Peking duck” leaves its mark on the coronary artery, which doesn’t even know what it’s about! All these “delicacies” with a high fat content increase the level of cholesterol in the blood, which in the vast majority of cases is the cause of the development of atherosclerosis - one of the most terrible and difficult to treat (if curable at all) diseases, which can affect all our arterial vessels. And the coronary arteries of the heart are, unfortunately, in the first row. Deposited on the inner surface of the arteries, cholesterol gradually but surely turns into an atherosclerotic plaque, which, in addition to cholesterol, contains calcium, which makes the plaque uneven and hard. It is these plaques that are the anatomical substrate for the development of IHD. Atherosclerotic plaques can form in one vessel, then they speak of a single-vessel lesion, or they can form in several coronary arteries, which is called, respectively, multi-vessel lesion, in the case when the plaques are located in several vessels in each, then this is called multifocal (widespread) coronary atherosclerosis arteries. Depending on the development of the plaque, the lumen of the coronary artery narrows from minor stenosis (narrowing) to complete occlusion (blockage). This is the reason for the disruption of blood delivery to the heart muscle, causing ischemia or necrosis (infarction). The cells of the heart muscle are extremely sensitive to the level of oxygen in the incoming blood and therefore, any decrease in it negatively affects the functioning of the entire heart.

Symptoms of IHD.

In addition to standard complaints of pain in the chest, IHD can be manifested by disturbances in heart rhythm, shortness of breath or, simply, general weakness, fatigue and decreased performance. All these symptoms that appear in middle age, namely, after 30, should be interpreted in favor of suspicion of ischemic heart disease and serve as a reason for a thorough examination.

The logical conclusion of untreated or inadequately treated coronary artery disease is myocardial infarction or cardiac arrhythmias incompatible with life - ventricular fibrillation, which is commonly called “cardiac arrest”.

Methods for diagnosing ischemic heart disease

It’s a shame that in most cases, everything “frightening” can be avoided if you just consult a specialist in time. Modern medicine has many tools that allow us to examine the state of the cardiovascular system to the finest detail, make a timely diagnosis and determine further treatment tactics. One of the simplest and most widely available methods for examining the heart is electrocardiography (ECG). This decades-tested “friend” can register changes characteristic of myocardial ischemia and give rise to deeper thought. In this case, the methods of stress tests, ultrasound examination of the heart, as well as radioisotope research methods are highly informative. But first things first. Stress tests (the most popular of them are the “bicycle ergometer test”) allow you to identify areas of myocardial ischemia that occur during physical activity, as well as determine the “tolerance” threshold, which indicates the reserve capabilities of your cardiovascular system. Ultrasound examination of the heart, ECHO cardiography, allows you to assess the general contractility of the heart, evaluate its size, the condition of the valve apparatus of the heart (for those who have forgotten the anatomy, let me remind you - the atria and ventricles are separated by valves, tricuspid on the right and mitral on the left, as well as two more valves that block the exits from the ventricles , from the right - the valve of the pulmonary artery trunk, and from the left - the aortic valve), and also to identify areas of the myocardium affected by ischemia or from a heart attack. The results of this study largely determine the choice of treatment strategy in the future. These methods can be performed on an outpatient basis, that is, without hospitalization, which cannot be said about the radioisotope method of studying the perfusion (blood supply) of the heart. This method allows you to accurately record areas of the myocardium experiencing blood “starvation” - ischemia. All these methods underlie the examination of a patient with suspected ischemic heart disease. However, the “gold standard” for diagnosing coronary artery disease is coronary angiography. This is the only method that allows you to absolutely accurately determine the degree and location of damage to the coronary arteries of the heart and is decisive in the choice of further treatment tactics. The method is based on X-ray examination of the coronary arteries into the lumen of which a radiopaque substance is injected. This study is quite complex and is carried out only in specialized institutions. Technically, this procedure is performed as follows: under local anesthesia, a catheter is inserted into the lumen of the femoral (possibly also through the arteries of the upper extremities), which is then advanced upward and installed into the lumen of the coronary arteries. A contrast agent is supplied through the lumen of the catheter, the distribution of which is recorded using a special X-ray unit. Despite the alarming complexity of this procedure, the risk of complications is minimal, and the experience in performing this examination numbers in the millions.

Treatment methods for ischemic heart disease.

Another method of treating coronary artery disease is the method of interventional cardiology - angioplasty and stenting of the coronary arteries. The undeniable advantage of this method is the ratio of traumatism and effectiveness. The procedure is carried out in the same way as coronary angiography with the only difference being that during this procedure a special balloon is introduced into the lumen of the artery, by inflating which it is possible to expand the lumen of the narrowed coronary artery; in some cases, to prevent repeated stenosis (restenosis), a metal stent is installed in the lumen of the artery . However, the use of this method is sharply limited. This is due to the fact that a good effect from it is expected only in strictly defined cases of atherosclerotic lesions; in other, more severe situations, it may not only not give the expected result, but also cause harm. Moreover, the duration of results and effects from angioplasty and stenting, according to many studies, are significantly inferior to the surgical method of treating coronary artery disease. And that is why the operation of direct myocardial revascularization, today, is generally considered the most adequate method of treating coronary artery disease.

Today, there are two methods of coronary artery bypass surgery that are fundamentally different from each other - traditional coronary artery bypass grafting and minimally invasive aorto-coronary bypass surgery, which entered widespread clinical practice no more than 10 years ago and has made a real revolution in coronary surgery.

Traditional coronary artery bypass grafting is performed through a large access (sternotomy-longitudinal dissection of the sternum), while the heart is stopped and, as a result, using a heart-lung machine.

The minimally invasive technique of coronary artery bypass grafting involves performing the operation on a beating heart and without the use of a heart-lung machine. This made it possible to radically change approaches to surgical approaches, making it possible in a large percentage of cases not to resort to a large sternotomy access, but to perform the required volume of surgery through the so-called mini-accesses: ministernotomy or minithoracotomy. All this made it possible to make these operations less traumatic, to avoid numerous complications inherent in the use of artificial blood circulation (the development in the postoperative period of complex disorders of the blood coagulation system, the development of complications from the central nervous system, lungs, kidneys and liver), and also, which is extremely important, significantly expand the indications for coronary artery bypass surgery, making it possible to surgically treat a large category of patients for whom surgery under artificial circulation was contraindicated due to the severity of their condition, both in terms of heart function and other chronic diseases. This group of patients includes patients with chronic renal failure, with cancer, who have suffered cerebrovascular accidents in the past, and many others.

However, regardless of the method of surgical treatment, the essence of the operation is the same and consists in creating a blood flow path (shunt) bypassing the stenotic section of the coronary artery. In the traditional version, the operation is technically performed as follows. Under general anesthesia, a median sternotomy is performed, while another team of surgeons isolates the so-called great saphenous vein of the leg, which subsequently becomes a shunt. Veins can be taken from one leg or, if necessary, from both legs. When performing an operation under artificial circulation, the next step is to connect the artificial circulation machine and stop the heart. In this case, the maintenance of the vital functions of the entire organism is carried out exclusively due to this apparatus. In the case of an operation using a new method, that is, on a beating heart, this stage is absent, the heart does not stop and, accordingly, all body systems continue to work as usual. The main stage of the operation is the implementation of so-called anastomoses, connections between the bypass (former vein) and, on the one hand, with the aorta, and on the other hand, with the coronary artery. The number of shunts corresponds to the number of affected coronary arteries.

Recently, the technique of minimally invasive myocardial revascularization has increasingly begun to be used - performing the operation through mini-accesses, the length of which does not exceed 5 - 6 cm. In this case, various options are possible, this could be ministernotomy (longitudinal partial dissection of the sternum, which allows not to disturb its stability), and minithoracotomy (access passing between the ribs, that is, without crossing the bones). In this case, the risk of developing many postoperative complications, such as sternal instability and purulent complications, is minimized. Significantly less pain in the postoperative period.

In addition to veins, the so-called internal mammary artery, which runs along the inner surface of the anterior chest wall, as well as the radial artery (the same artery on which we feel our pulse from time to time) can be used as shunts. It is generally accepted that the internal mammary and radial arteries are superior in quality to venous shunts. However, the decision to use one or another type of shunt is decided individually in each case.

Postoperative period

From the very first hour after surgery, the healing process of tissues cut during surgery begins. The time required for complete restoration of integrity varies for different tissues: the skin and subcutaneous fat heal relatively quickly - about 10 days, and the process of fusion of the sternum takes two months. And in these two months you need to create the most favorable conditions for this process, which boils down to minimizing the load on this area. To do this, for one month you need to sleep only on your back, hold your chest with one hand when coughing, refrain from lifting heavy objects, sharp bends, throwing your hands behind your head, and it is also advisable to constantly wear a chest corset for about two months. You only need to get out of bed and lie down on it: either with the help of another person who would lift and lower you by the neck, completely bearing the weight of your body, or with a rope tied in front to the side of the bed, so that you rise and fall due to the strength of the arms, and not the abs and pectoral muscles. It is also necessary to remember that even after two months it is necessary to avoid heavy physical exertion on the shoulder girdle and prevent injuries to the sternum.

If you had surgery through a mini-access, then these precautions are unnecessary.

You can take water procedures only after the sutures are removed, i.e., after restoring the integrity of the skin in the area of the postoperative incision, however, the area of the sutures should not be intensively rubbed with a washcloth and it is better to refrain from taking hot baths for two weeks after the removal of the sutures.

As mentioned above, the large saphenous vein taken from the lower leg could serve as a shunt, and due to the resulting redistribution of blood outflow, swelling of the lower extremities and pain may appear for 1 - 1.5 months, which, in principle, is a variant of the norm. And although there is nothing wrong with this, it is still better to avoid this, for which you need to bandage your leg with an elastic bandage and exactly as your doctor showed you. The bandage is applied in the morning, before getting out of bed, and removed at night. It is advisable to sleep with your foot on a raised platform.

Much attention in the rehabilitation process after CABG is paid to the restoration of physical activity. A gradual, day-by-day increase in physical activity is a necessary factor in your quick return to a full life. And here walking occupies a special place, being the most familiar and physiological way of training; it significantly improves the functional state of the myocardium, increasing its reserve capabilities and strengthening the heart muscle. You can start walking immediately after being transferred to the ward, but the training process is based on strict rules that help avoid complications.

1) Before walking, you need to rest for 5-7 minutes and count your pulse.

2) The walking pace should be 70−90 steps per minute (4.0−5.0 km/h).

3) The heart rate should not exceed the so-called training level, which is calculated using the following formula: Your initial heart rate plus 60% of its increase during exercise. The pulse during exercise, in turn, is 190 - Your age. For example: You are 50 years old, therefore, your heart rate during exercise will be 190 - 50 = 140. Your resting heart rate is 70 beats per minute. The increase is 140 – 70 = 70, 60% of this number is 42. Thus, the training pulse purity should be 70 + 42 = 112 beats per minute.

4) You can walk in any weather, but not below the air temperature - 20 or - 15 with wind.

5) The best walking time is from 11 am to 1 pm and from 5 pm to 7 pm.

6) While walking, it is prohibited to talk and smoke.

7) By the end of your stay in the hospital, you should walk about 300 - 400 meters per day, with a gradual increase in walking over the next 6 months to 3 - 3.5 km twice a day, i.e. 6 - 7 km per day.

8) If you experience pain in the heart area, weakness, dizziness, etc. It is necessary to stop the exercise and consult a doctor.

9) When walking, it is advisable to monitor your posture.

In addition to walking, climbing stairs has a very good training effect. In this case, the following rules must also be observed:

1) For the first two weeks, climb no more than one or two floors.

3) Inhalation is done at rest, while exhaling, 3-4 steps are overcome, rest pause.

4) The assessment of one’s preparedness is determined by the pulse rate, and when climbing 4 - 5 floors at a normal pace (60 steps in one minute), the result is excellent if the pulse does not exceed 100 beats, 120 beats are good, 140 are satisfactory and bad if the pulse rate more than 140 strokes.

Of course, physical exercise in no way replaces medications or other medical procedures, but is an indispensable addition to them. They can significantly reduce the duration of the rehabilitation period and help return to normal life. And although, when you are discharged from the hospital and are no longer under the constant supervision of doctors, their implementation is entirely up to you, we strongly recommend that you continue physical training, adhering to the proposed scheme. It should be noted that the rehabilitation process is completely completed approximately by the sixth month after the operation.

Despite the fact that in the modern state of medicine, psychological trauma from the operation is reduced to a minimum, this aspect of rehabilitation is not the least important in the overall complex of rehabilitation measures and almost entirely depends on the patient himself. Self-hypnosis (autogenic training) is of great importance here, as it can significantly set you up optimistically for the upcoming rehabilitation process, subsequent life, and instill confidence and strength. But if, after the operation, you are bothered by “mental discomfort” and the associated feelings of anxiety, fear, insomnia, and you have become irritable, then you can resort to medication correction. In such conditions, sedatives have a good effect: motherwort herb, valerian root, corvalol, etc. Sometimes the situation turns out to be completely opposite and you feel weakness, lethargy, apathy, depression, then in these cases it is advisable to use so-called antidepressants, naturally after consultation with your attending physician. However, in many cases it is possible to do without the use of medications and this is largely facilitated by the physical training method described above; A good effect was obtained during a course of general massage. The process of labor and social adaptation largely depends on how stable your psychological state is.

In the life of every person, a favorite job occupies a large place, and returning to it after surgery has enormous social and personal significance. Despite the fact that CABG is regarded as a highly effective method of treating coronary artery disease, capable of almost completely eliminating the symptoms of this disease and returning you to a full life, there are still limitations associated with both the underlying disease and the operation itself. Many of them apply to the area of your work activity. Such difficult professions that require high concentration, which in addition to high physical costs entail high nervous tension, are contraindicated for you. It is extremely undesirable to work associated with significant physical stress, being in meteorologically unfavorable areas with low temperatures and strong winds, exposure to toxic substances, as well as working on the night shift. Of course, giving up your favorite profession is very difficult. However, returning to it, you need to create for yourself the most gentle and comfortable conditions possible. Try to avoid nervous stress, overwork, physical activity, strictly follow the regime, giving yourself the opportunity to rest and fully recover.

Among the factors that determine the degree of postoperative adaptation, the process of sexual rehabilitation occupies a special place. And it seems to us unacceptable to ignore such an important issue. We are aware that the intimate life of every person is closed to advice and, even more so, restrictions. But taking a certain amount of courage, we want to warn you against the dangers that may lie in wait in the early stages of returning to sexual activity after surgery. The tension experienced during coitus is equivalent to performing heavy physical activity and this should not be forgotten. During the first two three weeks, you should completely avoid active sex, and during the next two months, the role of a passive partner is preferable, which will help reduce energy costs to a minimum and thereby minimize the risk of possible complications from the cardiovascular system. However, we can say with a high degree of confidence that at the end of the rehabilitation process you will be able to fully return to your usual personal life.

In our recommendations, we would like to give a special place to advice regarding diet and diet. You certainly know that the main cause of IHD is atherosclerotic damage to the coronary vessels. And surgical treatment only partly solves this problem, providing beds that bypass the section of the heart artery narrowed by cholesterol plaque. But unfortunately, surgery is completely powerless against the possibility of progression of atherosclerotic lesions of the coronary vessels in the future and, as a consequence of this, the return of symptoms of insufficient blood supply to the myocardium. Such a sad course of events can only be prevented by following a strict diet aimed at reducing cholesterol and fat, as well as reducing the total calorie content of the diet to 2500 calories per day. The World Health Organization has developed and tested a dietary nutrition system, which we strongly recommend to you.

Calorie intake from different foods is distributed as follows:

1. Total fats no more than 30% of total calories.

saturated fat less than 10% of total calories.

polyunsaturated fats less than 10% of total calories.

monounsaturated fats 10% to 15% of total calories

2. Carbohydrates from 50% to 60% of total calories.

3. Proteins from 10% to 20% of total calories.

4. Cholesterol less than 300 mg per day.

But to achieve the desired result, you need to use only those products, the consumption of which ensures both the supply of all necessary nutrients to the body and compliance with the diet. Therefore, your diet should be well balanced and thought out. We would like to recommend that you use the following products:

1. Meat. Use lean cuts of beef, lamb or pork. Before cooking, remove all fat from them and it is better if the meat is cooked using vegetable oils when frying or, even more preferably, boiled. It is necessary to limit the consumption of sub-products: liver, kidneys, brains due to their high cholesterol content.

2. Bird. Clear preference is given to lean white (breast) chicken meat. It is also better to cook it in vegetable oils or by boiling it. Before cooking, it is advisable to remove the skin, which is rich in cholesterol.

4 eggs. The consumption of egg yolk, due to its high cholesterol content, should be reduced to 2 pieces per week. However, protein intake is not limited.

5. Fish and seafood products. Fish contains little fat and many useful and essential mineral elements. Preference is given to lean varieties of fish and cooking without the use of animal fats. It is extremely undesirable to consume shrimp, squid and crabs, as well as caviar due to the large amount of cholesterol they contain.

6. Fats and oils. Despite the fact that they are undisputed culprits in the development of atherosclerosis and obesity, it is not possible to completely exclude them from the daily diet. It is necessary to sharply limit the consumption of those foods that are rich in saturated fats - lard, pork and lamb fats, hard margarine, butter. Preference is given to liquid fats of vegetable origin - sunflower, corn, olive, as well as soft margarine. Their amount should not exceed 30 - 40 grams per day.

7. Vegetables and fruits. We would like to note that vegetables and fruits should be an integral part of your daily diet. Unconditional preference is given to fresh and freshly frozen vegetables and fruits. You should refrain from consuming sweet compotes, jams, preserves, and candied fruits. There are no special restrictions on the consumption of vegetables. All of them are a source of vitamins and minerals. But in preparing them, you should reduce the use of animal fats, replacing them with vegetable ones. The consumption of nuts should be limited, and although they contain mainly vegetable fats, their calorie content is extremely high.

8. Flour and bakery products. Their consumption can be increased by replacing fatty foods, but given their high calorie content, it should not be excessive. Preference is given to rye and bran bread. Oatmeal cooked in water has a pronounced anticholesterolemic effect. Buckwheat and rice cereals are not without healing properties. Confectionery products, baked goods, chocolate, ice cream, marmalade, and marshmallows should be limited as much as possible. This applies to a lesser extent to pasta; they contain virtually no fat, and their consumption is limited only due to their high calorie content.

If cholesterol levels cannot be reduced through diet, then this should be done by resorting to drug therapy, preferably under medical supervision. In order to timely diagnose hypercholesterolemia, regular checking of its level in the blood is necessary.

I would like to draw your attention to the fact that if any questions arise, especially if your blood pressure increases or if any unpleasant sensations appear in the heart area, you should immediately contact the doctors who operated on you, since only they have the most complete information about the condition of your heart. – the vascular system and the intricacies of the operation performed. It is also advisable to undergo a re-examination after half a year, and then a year later, which must necessarily include a repeat coronary angiography.

III-IV FC means that pharmacotherapy is not effective enough. The indications and nature of surgical treatment are clarified based on the results of coronary angiography, depending on the degree, prevalence and characteristics of the lesion of the coronary arteries.
There are 2 main methods of surgical treatment of coronary artery disease: balloon coronary angioplasty (CAB) and coronary artery bypass grafting (CABG).
The absolute indications for CABG are the presence of left main coronary artery stenosis or three-vessel disease, especially if the ejection fraction is reduced. In addition to these two indications, CABG is appropriate in patients with two-vessel disease if there is proximal stenosis of the left anterior descending branch. CABG in patients with stenosis of the left main coronary artery increases the life expectancy of patients compared with drug treatment (5-year survival after CABG is 90%, with drug treatment - 60%). CABG is somewhat less effective for three-vessel disease in combination with left ventricular dysfunction.
CAP is a method of so-called invasive (or interventional) cardiology. The long-term results of CAP have not yet been sufficiently studied. In any case, a symptomatic effect - the disappearance of angina - is observed in most patients.

Coronary angioplasty

The essence of the CAP procedure is the crushing of an atherosclerotic plaque using a catheter with an inflatable balloon (Fig. 65).

Rice. 65. Balloon coronary angioplasty:

A - critical stenosis of the coronary artery; B - insertion of a probe with an inflating balloon into the coronary artery; B - inflation of the balloon and crushing of the plaque; D - almost complete restoration of blood flow in the affected artery

In addition to CAP, various other methods are used to destroy the atherosclerotic plaque using laser or ultrasound, direct and rotational atherectomy.
The “ideal” coronary artery lesion for CAP is a short (less than 1 cm), proximal, concentric, straight and smooth, non-calcified stenosis. With this option (type A - discrete stenosis), CAP is effective in more than 85% of patients. Several small concentric stenoses can be easily corrected. With more extensive (up to diffuse) stenosis, calcification, pronounced bends, eccentric stenoses or complete occlusion (types B and C), the risk of CAP is higher, and the effectiveness is lower: about 60-85% with type B and less than 60% with type C.
Indications for CAP are continuously expanding with improvements in implementation techniques. Nowadays, CAP is also performed in cases of three-vessel disease, multiple stenoses in one coronary artery with stenosis in coronary artery bypass grafts, and even in cases of damage to the trunk of the left coronary artery. The main complication is intimal detachment with thrombosis and occlusion. The risk of CAP is relatively small, with a mortality rate of less than 1%. The need for emergency CABG is less than 3%, the probability of myocardial infarction during CABG is less than 5%. The criteria for successful CAP are an increase in the diameter of the stenotic area by at least 20% with restoration of more than 50% of the lumen of the coronary artery and elimination of angina. Successful CAP is observed in 90% of patients.
The main problem of CAP is the frequent occurrence of restenosis. Early reocclusion during the first weeks or months is observed in 20-30% of patients, from 30 to 45% in the first 6-9 months and up to 70% after a year. Repeated CAP is almost always effective. But after repeated CAP, the risk of restenosis increases even more (“the patient often becomes a regular client of the cardiac surgeon”). To prevent restenosis, constant use of aspirin is prescribed (often in combination with clopidogrel). In addition, stents are inserted into the coronary arteries - metal or plastic endovascular prostheses (Fig. 66, 67).

With the use of stents, a decrease in the incidence of reocclusion and restenosis of the coronary arteries by 20-30% was noted. If after CAP there is no restenosis within a year, the prognosis for the next 3-4 years is very good.

Rice. 66. Coronary angioplasty procedure with stenting:
A - holding a balloon with a stent to the site of stenosis; B - coronary angioplasty with stent installation; B - after removal of the probe, the stent remains in the coronary artery

To create shunts between the aorta and segments of the coronary arteries distal to the stenoses, autografts from the saphenous veins of the leg are most often used (Fig. 68).

Rice. 67. Coronary angioplasty with stent installation:
A - initial coronary angiogram; B - diagram of the position of the stent in the coronary artery after eliminating the stenosis; B - coronary angiogram after Stenting

Rice. 68. Coronary artery bypass grafting
A subcutaneous shunt was placed between the aorta and the anterior descending artery.
calf veins

If possible, the internal mammary artery is used for bypass surgery (“MCB” - mammary coronary bypass). The internal mammary artery is connected to the coronary artery - the advantage of this method is the much longer preservation of the patency of the shunts - in approximately 95% of patients for 10 years. And when using saphenous veins, after 10 years the patency of the shunts remains in approximately 50% of patients (while occlusion of the shunts in the first few weeks is observed in 10%, within a year - in 15-20%, within 5-7 years - in 25- 30% of patients).
The more severe the angina, the less effective drug treatment is, since the severity of angina reflects the degree of reduction in coronary reserve. CABG eliminates this cause (revascularization). Therefore, it is not unexpected that the maximum effect of CABG is observed in patients with more severe coronary artery disease and impaired left ventricular function. The stronger the dysfunction of the left ventricle, the higher the risk of complications during surgery and in the postoperative period. But the greater the benefit from surgical intervention.
From a safety point of view, it would be “ideal” to perform CABG in patients with normal or slightly impaired left ventricular function, but then the benefit from the operation would also be insignificant. CABG is usually performed in patients with a decrease in EF of less than 50%, with the maximum effect observed in patients with more severe left ventricular dysfunction - with a decrease in EF of less than 40%. With extremely severe myocardial damage (EF less than 15-20%), there is usually almost no viable myocardium, so surgery in these cases is useless (such patients, as a rule, do not have angina, there are no areas of reversible ischemia, with the exception of the possible presence of areas of “sleeping” myocardium).
Contraindications for CABG are the absence of patent arteries with a lumen of 1 mm or more distal to the stenoses or the absence of viable myocardium in the area of the blood supply of the affected artery. Both of these conditions are quite rare.
Hospital mortality ranges from 1 to 4% (with normal EF - less than 1%), the occurrence of MI during CABG is observed in 2.5-5% of cases.

It is very important to quit smoking! Preferably before surgery. After surgery, all patients are prescribed aspirin or aspirin in combination with dipyridamole. Control of risk factors for coronary artery disease contributes to longer-term maintenance of shunt patency.
In recent years, the term “acute coronary syndrome (ACS)” has become widespread. ACS includes acute variants of coronary artery disease: unstable angina (UA) and myocardial infarction (MI). Since NS and MI are indistinguishable clinically, upon admission of the patient, after recording an ECG, one of two diagnoses is established: “acute coronary syndrome with segment elevation” ST» or “acute coronary syndrome without segment elevation ST». The final diagnosis of a particular type of ACS is always retrospective. In the first case, the development of MI with a wave is very likely Q, in the second, unstable angina or the development of non-wave MI are more likely Q. Dividing ACS into two options is primarily necessary for early initiation of treatment measures: for ACS with ST-segment elevation, the administration of thrombolytics is indicated, and for ACS without ST-segment elevation, thrombolytics are not indicated. It should be noted that during the examination of patients, a “non-ischemic” diagnosis may be identified, for example, PE, myocarditis, aortic dissection, neurocirculatory dystonia, or even extracardiac pathology, for example, acute diseases of the abdominal cavity.

Acute coronary syndromes begin with inflammation and rupture of a “vulnerable” plaque. During inflammation, activation of macrophages, monocytes and T-lymphocytes, production of inflammatory cytokines and secretion of proteolytic enzymes are observed. A reflection of this process is an increase in the level of markers of the acute phase of inflammation (acute phase reactants) in ACS, for example, C-reactive protein, amyloid A, interleukin-6. As a result, damage to the plaque capsule occurs, followed by rupture. The pathogenesis of ACS can be represented as the following sequence of changes:
♦ inflammation of the “vulnerable” plaque;
♦ plaque rupture;
♦ platelet activation;
♦ vasoconstriction;
♦ thrombosis.
The interaction of these factors, progressively increasing, can lead to the development of myocardial infarction or death.
In ACS without ST segment elevation, a non-occlusive “white” thrombus is formed, consisting predominantly of platelets. A “white” thrombus can be a source of microembolism in smaller myocardial vessels with the formation of small foci of necrosis (“microinfarctions”). In ACS with ST segment elevation, a “white” thrombus forms an occlusive “red” thrombus, which consists predominantly of fibrin.
As a result of thrombotic occlusion of the coronary artery, transmural myocardial infarction develops.
The only method for diagnosing one or another variant of ACS is recording an ECG. When ST segment elevation is detected, in 90% of cases, MI with a Q wave develops. In patients without persistent ST segment elevation, ST segment depression, negative T waves, pseudonormalization of inverted T waves, or no ECG changes are observed (in addition, in approximately 10% of patients with ACS without persistent ST segment elevation, episodes of transient ST segment elevation are observed). The probability of MI with a Q wave or death within 30 days in patients with ST segment depression averages about 12%, when recording negative T waves - about 5%, in the absence of ECG changes - from 1 to 5%. MI with Q wave is diagnosed by ECG (appearance of Q wave). To detect MI without a Q wave, it is necessary to determine markers of myocardial necrosis in the blood. The method of choice is to determine the level of cardiac troponins T or I. In second place is to determine the mass or activity of the MB fraction of creatine phosphokinase (MB CPK). A sign of MI is considered to be a troponin T level greater than
0.1 µg/l (troponin I - more than 0.4 µg/l) or an increase in CK MB by 2 times or more. In approximately 30% of patients with increased levels of troponins in the blood (“troponin-positive” patients), CPK MB is within normal limits. Therefore, when using the determination of troponins, the diagnosis of MI will be made in a larger number of patients than when using MB CPK (an increase in troponins can also be observed in non-ischemic myocardial damage, for example, in PE, myocarditis, HF and chronic renal failure).

Surgical treatment of coronary heart disease has gone through several stages of development. The first of them is on the sympathetic part of the nervous system, the purpose of which is to interrupt the paths of pain and eliminate spasm of the coronary vessels. This is a surgical continuation of pharmacotherapy.

Substernal novocaine blockades and removal of the stellate ganglion (C8 and T1) - stelectomy were also used.

The next stage in the development of surgical treatment of coronary heart disease is represented by indirect methods of myocardial revascularization using suturing of the pericardium (Thompson), skeletal mice (Beck), and omentum (O’Shaughnessy). These operations are also ineffective, since any cicatricial adhesions between organs after the vascular stage (red scar) become avascular (white scar).

Surgical treatment came to the forefront of the fight against coronary heart disease after Favalloro performed the first operations in 1958 coronary artery bypass grafting (CABG), thereby beginning the stage of direct reconstructive operations on the coronary vessels. The development of this method was preceded by the introduction into practice of a complex research method - selective coronary angiography, which makes it possible to determine the locations of narrowings of the coronary arteries. Thanks to coronary angiography, it was established that the damage to these vessels is not diffuse, but segmental in nature, and therefore they can be bypassed.

The principle of CABG is simple: a shunt is placed between the ascending aorta and the coronary vessel distal to the site of narrowing. The shunt can be an autovenous or autoartery. xenograft, implant. Coronary artery bypass grafting is currently considered as an emergency operation for acute myocardial infarction. A timely operation can prevent or significantly reduce the area of myocardial necrosis. If necessary, multiple shunts can be placed.

Thoracocoronary bypass surgery. Professor Kolesov of the Military Medical Academy of St. Petersburg proposed an alternative CABG operation - an end-to-side anastomosis, which is placed between the internal mammary artery and the coronary vessel. The operation is less effective, but has its advantages. First, one anastomosis is performed instead of two. Secondly, it is possible to avoid the dangerous stage of surgery on the reflexogenic area of the aorta. Third, the surgery prevents scarring of the shunt as it is connected to the body.

Surgical treatment of heart rhythm disorders. As part of the cardiac conduction system, the number of fibers that transmit impulses decreases with age. and the percentage of connective tissue increases. If elements of the conduction system of the heart find themselves in unfavorable conditions (coronary artery disease, heart attack), then this process accelerates and leads to heart rhythm disturbances. There are transverse and longitudinal atrioventricular blocks. With transverse blockade, the connection between the sinus-atrial and atrioventricular parts of the conduction system is disrupted. Incomplete blockade is possible, when ventricular contractions occur at certain intervals (Adams-Stokes syndrome), and complete blockade (transverse block). With transverse blockade, the atria contract at a normal rhythm - 65-80 contractions per 1 minute (sinus rhythm), and the ventricles - at a frequency of 40-50 per 1 minute thanks to second-order pacemakers.

Heart and its coronary arteries

The heart is an amazingly complex and at the same time reliable organ. From the moment we are born until the last moment of our life, it works continuously, without rest or breaks for sleep. Over a life of 70 years, the heart makes approximately 220,7520,000 contractions to ensure this life, and pumps 132,4512,000 liters of blood.
The main function of the heart is pumping; by ejecting blood from its cavities, the heart ensures the delivery of oxygen-enriched blood to all organs and tissues of our body.
The heart is a muscular hollow organ, physiologically divided into two sections - right and left. The right section, right atrium and right ventricle belong to the pulmonary circulation, while the left section, which also consists of the left atrium and left ventricle, belongs to the systemic circulation.
Despite this “frivolous” division of the departments of the heart into “large” and “small”, this does not affect the significance of these departments in any way - both of them have vital importance. The right parts of the heart, namely the right atrium, receives blood flowing from the organs, that is, already exhausted and poor in oxygen, then this blood enters the right ventricle, and from there through the pulmonary trunk into the lungs, where gas exchange occurs as a result of which the blood is enriched with oxygen . This blood enters the left atrium, then into the left ventricle, and from it through the aorta it is “thrown out” into the systemic circulation, carrying the oxygen necessary for every cell of our body.
But to perform this “titanic” work, the heart also needs oxygenated blood. And it is the coronary arteries of the heart, whose diameter does not exceed 2.5 mm and are the only way to deliver blood to the heart muscle. In this regard, there is no need to talk about the importance of the coronary arteries.

Reasons for the development of IHD

Symptoms of IHD

The first signal of the disease is attacks of chest pain (angina pectoris), which occurs during physical activity, psycho-emotional stress, increased blood pressure, or simply at rest. However, there is no direct dependence on the degree of damage to the coronary arteries and the severity of clinical symptoms. There are cases where patients with critical damage to the coronary arteries felt quite well and did not make any complaints, and only the experience of their doctors made it possible to suspect a lurking disease and save the patients from inevitable disaster. These rare cases belong to the category of so-called “silent” or painless ischemia and are an extremely dangerous condition.
In addition to standard complaints of pain in the chest, IHD can be manifested by disturbances in heart rhythm, shortness of breath or, simply, general weakness, fatigue and decreased performance. All these symptoms that appear in middle age, namely, after 30, should be interpreted in favor of suspicion of ischemic heart disease and serve as a reason for a thorough examination.
The logical conclusion of untreated or inadequately treated coronary artery disease is myocardial infarction or cardiac arrhythmias incompatible with life - ventricular fibrillation, which is commonly called “cardiac arrest”.

Methods for diagnosing ischemic heart disease

Treatment methods for coronary artery disease

Modern medicine has all the necessary arsenal of methods for treating coronary artery disease, and what is especially important is that all the proposed methods have extremely extensive experience. Of course, the oldest and most proven method of treating IHD is medication. However, the modern concept of the approach to the treatment of coronary artery disease clearly leans towards more aggressive methods of treating this disease. The use of drug therapy is limited either to the initial stage of the disease, or to situations where the choice of further tactics has not yet been fully determined, or in those stages of the disease when surgical correction or angioplasty is impossible due to severe widespread atherosclerosis of the coronary arteries of the heart. Thus, drug therapy is not able to adequately and radically solve the situation and, according to numerous scientific data, is significantly inferior to surgical treatment or angioplasty.
Another method of treating coronary artery disease is the method of interventional cardiology - angioplasty and stenting of the coronary arteries. The undeniable advantage of this method is the ratio of traumatism and effectiveness. The procedure is carried out in the same way as coronary angiography with the only difference being that during this procedure a special balloon is introduced into the lumen of the artery, by inflating which it is possible to expand the lumen of the narrowed coronary artery; in some cases, to prevent repeated stenosis (restenosis), a metal stent is installed in the lumen of the artery . However, the use of this method is sharply limited. This is due to the fact that a good effect from it is expected only in strictly defined cases of atherosclerotic lesions; in other, more severe situations, it may not only not give the expected result, but also cause harm. Moreover, the duration of results and effects from angioplasty and stenting, according to many studies, are significantly inferior to the surgical method of treating coronary artery disease. And that is why the operation of direct myocardial revascularization, today, is generally considered the most adequate method of treating coronary artery disease.
Today, there are two methods of coronary artery bypass surgery that are fundamentally different from each other - traditional coronary artery bypass grafting and minimally invasive aorto-coronary bypass surgery, which entered widespread clinical practice no more than 10 years ago and has made a real revolution in coronary surgery.
Traditional coronary artery bypass grafting is performed through a large access (sternotomy-longitudinal dissection of the sternum), while the heart is stopped and, as a result, using a heart-lung machine.
The minimally invasive technique of coronary artery bypass grafting involves performing the operation on a beating heart and without the use of a heart-lung machine. This made it possible to radically change approaches to surgical approaches, making it possible in a large percentage of cases not to resort to a large sternotomy access, but to perform the required volume of surgery through the so-called mini-accesses: ministernotomy or minithoracotomy. All this made it possible to make these operations less traumatic, to avoid numerous complications inherent in the use of artificial blood circulation (the development in the postoperative period of complex disorders of the blood coagulation system, the development of complications from the central nervous system, lungs, kidneys and liver), and also, which is extremely important, significantly expand the indications for coronary artery bypass surgery, making it possible to surgically treat a large category of patients for whom surgery under artificial circulation was contraindicated due to the severity of their condition, both in terms of heart function and other chronic diseases. This group of patients includes patients with chronic renal failure, with cancer, who have suffered cerebrovascular accidents in the past, and many others.
However, regardless of the method of surgical treatment, the essence of the operation is the same and consists in creating a blood flow path (shunt) bypassing the stenotic section of the coronary artery. In the traditional version, the operation is technically performed as follows. Under general anesthesia, a median sternotomy is performed, while another team of surgeons isolates the so-called great saphenous vein of the leg, which subsequently becomes a shunt. Veins can be taken from one leg or, if necessary, from both legs. When performing an operation under artificial circulation, the next step is to connect the artificial circulation machine and stop the heart. In this case, the maintenance of the vital functions of the entire organism is carried out exclusively due to this apparatus. In the case of an operation using a new method, that is, on a beating heart, this stage is absent, the heart does not stop and, accordingly, all body systems continue to work as usual. The main stage of the operation is the implementation of so-called anastomoses, connections between the bypass (former vein) and, on the one hand, with the aorta, and on the other hand, with the coronary artery. The number of shunts corresponds to the number of affected coronary arteries.
Recently, the technique of minimally invasive myocardial revascularization has increasingly begun to be used - performing the operation through mini-accesses, the length of which does not exceed 5 - 6 cm. In this case, various options are possible, this could be ministernotomy (longitudinal partial dissection of the sternum, which allows not to disturb its stability), and minithoracotomy (access passing between the ribs, that is, without crossing the bones). In this case, the risk of developing many postoperative complications, such as sternal instability and purulent complications, is minimized. Significantly less pain in the postoperative period.
In addition to veins, the so-called internal mammary artery, which runs along the inner surface of the anterior chest wall, as well as the radial artery (the same artery on which we feel our pulse from time to time) can be used as shunts. It is generally accepted that the internal mammary and radial arteries are superior in quality to venous shunts. However, the decision to use one or another type of shunt is decided individually in each case.

Postoperative period

For the first day, the patient is in the intensive care unit under constant monitoring and medical supervision with strict bed rest, which is canceled from the moment of transfer to the department - approximately on the second or third day.
From the very first hour after surgery, the healing process of tissues cut during surgery begins. The time required for complete restoration of integrity varies for different tissues: the skin and subcutaneous fat heal relatively quickly - about 10 days, and the process of fusion of the sternum takes two months. And in these two months you need to create the most favorable conditions for this process, which boils down to minimizing the load on this area. To do this, for one month you need to sleep only on your back, hold your chest with one hand when coughing, refrain from lifting heavy objects, sharp bends, throwing your hands behind your head, and it is also advisable to constantly wear a chest corset for about two months. You only need to get out of bed and lie down on it: either with the help of another person who would lift and lower you by the neck, completely bearing the weight of your body, or with a rope tied in front to the side of the bed, so that you rise and fall due to the strength of the arms, and not the abs and pectoral muscles. It is also necessary to remember that even after two months it is necessary to avoid heavy physical exertion on the shoulder girdle and prevent injuries to the sternum.
If you had surgery through a mini-access, then these precautions are unnecessary.
You can take water procedures only after the sutures are removed, i.e., after restoring the integrity of the skin in the area of the postoperative incision, however, the area of the sutures should not be intensively rubbed with a washcloth and it is better to refrain from taking hot baths for two weeks after the removal of the sutures.
As mentioned above, the large saphenous vein taken from the lower leg could serve as a shunt, and due to the resulting redistribution of blood outflow, swelling of the lower extremities and pain may appear for 1 - 1.5 months, which, in principle, is a variant of the norm. And although there is nothing wrong with this, it is still better to avoid this, for which you need to bandage your leg with an elastic bandage and exactly as your doctor showed you. The bandage is applied in the morning, before getting out of bed, and removed at night. It is advisable to sleep with your foot on a raised platform.
Much attention in the rehabilitation process after CABG is paid to the restoration of physical activity. A gradual, day-by-day increase in physical activity is a necessary factor in your quick return to a full life. And here walking occupies a special place, being the most familiar and physiological way of training; it significantly improves the functional state of the myocardium, increasing its reserve capabilities and strengthening the heart muscle. You can start walking immediately after being transferred to the ward, but the training process is based on strict rules that help avoid complications.
- Before walking, you need to rest for 5-7 minutes and count your pulse.
- The walking pace should be 70-90 steps per minute (4.0-5.0 km/h).
- The heart rate should not exceed the so-called training level, which is calculated according to the following formula: Your initial heart rate plus 60% of its increase during exercise. The pulse during exercise, in turn, is 190 - Your age. For example: You are 50 years old, therefore, your heart rate during exercise will be 190 - 50 = 140. Your resting heart rate is 70 beats per minute. The increase is 140 – 70 = 70, 60% of this number is 42. Thus, the training pulse purity should be 70 + 42 = 112 beats per minute.
- You can walk in any weather, but not below the air temperature - 20 or - 15 with wind.
- The best walking times are from 11 a.m. to 1 p.m. and from 5 p.m. to 7 p.m.
- It is prohibited to talk or smoke while walking.
- By the end of your stay in the hospital, you should walk about 300 - 400 meters per day, with a gradual increase in walking over the next 6 months to 3 - 3.5 km twice a day, i.e. 6 - 7 km per day.
- If you experience pain in the heart area, weakness, dizziness, etc. It is necessary to stop the exercise and consult a doctor.
- When walking, it is advisable to monitor your posture.
In addition to walking, climbing stairs has a very good training effect. In this case, the following rules must also be observed:
- For the first two weeks, climb no more than one or two floors.
- The recommended pace is to climb 3–4 floors, covering 60 steps in 1 minute.
- Inhalation is done at rest, while exhaling, 3-4 steps are overcome, rest pause.
- The assessment of one’s readiness is determined by the pulse rate, and when climbing 4 – 5 floors at a normal pace (60 steps in one minute), the result is excellent if the pulse does not exceed 100 beats, 120 beats are good, 140 are satisfactory and bad if the pulse rate is more than than 140 strokes.
Of course, physical exercise in no way replaces medications or other medical procedures, but is an indispensable addition to them. They can significantly reduce the duration of the rehabilitation period and help return to normal life. And although, when you are discharged from the hospital and are no longer under the constant supervision of doctors, their implementation is entirely up to you, we strongly recommend that you continue physical training, adhering to the proposed scheme. It should be noted that the rehabilitation process is completely completed approximately by the sixth month after the operation.
Despite the fact that in the modern state of medicine, psychological trauma from the operation is reduced to a minimum, this aspect of rehabilitation is not the least important in the overall complex of rehabilitation measures and almost entirely depends on the patient himself. Self-hypnosis (autogenic training) is of great importance here, as it can significantly set you up optimistically for the upcoming rehabilitation process, subsequent life, and instill confidence and strength. But if, after the operation, you are bothered by “mental discomfort” and the associated feelings of anxiety, fear, insomnia, and you have become irritable, then you can resort to medication correction. In such conditions, sedatives have a good effect: motherwort herb, valerian root, corvalol, etc. Sometimes the situation turns out to be completely opposite and you feel weakness, lethargy, apathy, depression, then in these cases it is advisable to use so-called antidepressants, naturally after consultation with your attending physician. However, in many cases it is possible to do without the use of medications and this is largely facilitated by the physical training method described above; A good effect was obtained during a course of general massage. The process of labor and social adaptation largely depends on how stable your psychological state is.
In the life of every person, a favorite job occupies a large place, and returning to it after surgery has enormous social and personal significance. Despite the fact that CABG is regarded as a highly effective method of treating coronary artery disease, capable of almost completely eliminating the symptoms of this disease and returning you to a full life, there are still limitations associated with both the underlying disease and the operation itself. Many of them apply to the area of your work activity. Such difficult professions that require high concentration, which in addition to high physical costs entail high nervous tension, are contraindicated for you. It is extremely undesirable to work associated with significant physical stress, being in meteorologically unfavorable areas with low temperatures and strong winds, exposure to toxic substances, as well as working on the night shift. Of course, giving up your favorite profession is very difficult. However, returning to it, you need to create for yourself the most gentle and comfortable conditions possible. Try to avoid nervous stress, overwork, physical activity, strictly follow the regime, giving yourself the opportunity to rest and fully recover.
Among the factors that determine the degree of postoperative adaptation, the process of sexual rehabilitation occupies a special place. And it seems to us unacceptable to ignore such an important issue. We are aware that the intimate life of every person is closed to advice and, even more so, restrictions. But, having taken upon ourselves a certain amount of courage, we want to warn you against the dangers that
may lie in wait in the early stages of returning to sexual activity after surgery. The tension experienced during coitus is equivalent to performing heavy physical activity and this should not be forgotten. During the first two to three weeks, you should completely abandon active sex, and over the next two months, the role of a passive partner is preferable, which will help reduce energy costs to a minimum and thereby minimize the risk of possible complications from the cardiovascular system. However, we can say with a high degree of confidence that at the end of the rehabilitation process you will be able to fully return to your usual personal life.

In our recommendations, we would like to give a special place to advice regarding diet and diet. You certainly know that the main cause of IHD is atherosclerotic damage to the coronary vessels. And surgical treatment only partly solves this problem, providing blood flow bypassing the section of the heart artery narrowed by cholesterol plaque. But, unfortunately, surgery is completely powerless against the possibility of progression of atherosclerotic lesions of the coronary vessels in the future and, as a consequence of this, the return of symptoms of insufficient blood supply to the myocardium. Such a sad course of events can only be prevented by following a strict diet aimed at reducing cholesterol and fat, as well as reducing the total calorie content of the diet to 2500 calories per day. The World Health Organization has developed and tested a dietary nutrition system, which we strongly recommend to you.

Calorie intake from different foods is distributed as follows:

1. Total fats no more than 30% of total calories.
saturated fat less than 10% of total calories.
polyunsaturated fats less than 10% of total calories.
monounsaturated fats 10% to 15% of total calories
2. Carbohydrates from 50% to 60% of total calories.
3. Proteins from 10% to 20% of total calories.
4. Cholesterol less than 300 mg per day.
But to achieve the desired result, you need to use only those products, the consumption of which ensures both the supply of all necessary nutrients to the body and compliance with the diet.

Therefore, your diet should be well balanced and thought out. We would like to recommend that you use the following products:
1. Meat. Use lean cuts of beef, lamb or pork. Before cooking, remove all fat from them and it is better if the meat is cooked using vegetable oils when frying or, even more preferably, boiled. It is necessary to limit the consumption of sub-products: liver, kidneys, brains due to their high cholesterol content.

3. Dairy products. The consumption of dairy products, as a source of large amounts of substances necessary for the body, is an integral part of the daily diet. You should use skim milk, yoghurt, cottage cheese, kefir, fermented baked milk, and yogurt. Unfortunately, you will have to give up very tasty, but also very fatty cheese, especially processed cheese. The same applies to mayonnaise, full-fat sour cream and cream.
4 eggs. The consumption of egg yolk, due to its high cholesterol content, should be reduced to 2 pieces per week. However, protein intake is not limited.
5. Fish and seafood. Fish contains little fat and many useful and essential mineral elements. Preference is given to lean varieties of fish and cooking without the use of animal fats. It is extremely undesirable to consume shrimp, squid and crabs, as well as caviar due to the large amount of cholesterol they contain.

9. Drinks. Alcohol consumption should not exceed 20 grams per day in terms of ethyl alcohol. It is preferable to drink dry red wine and beer in quantities of up to 200 ml daily. You should limit your consumption of strong alcoholic drinks and sweet liqueurs.
If cholesterol levels cannot be reduced through diet, then this should be done by resorting to drug therapy, preferably under medical supervision. In order to timely diagnose hypercholesterolemia, regular checking of its level in the blood is necessary.
I would like to draw your attention to the fact that if any questions arise, especially if your blood pressure increases or if any unpleasant sensations appear in the heart area, you should immediately contact the doctors who operated on you, since only they have the most complete information about the condition of your heart. – the vascular system and the intricacies of the operation performed. It is also advisable to undergo a re-examination after six months, and then a year later, which must necessarily include a repeat coronary angiography.