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Comparing Off-Pump and On-Pump CABG Approaches

There are two basic forms of coronary artery bypass graft surgery (CABG): on-pump and off-pump. The traditional pathway of on-pump CABG involves use of a cardiopulmonary bypass machine, which temporarily takes on the role of the heart. Blood drains into the machine outside the body. Once carbon dioxide has been removed and oxygen added, the machine pumps refreshed blood out into the body through the circulatory system.

Patients “on the pump” take a cardioplegia solution medication that prevents the heart from beating. The surgeon works on the still, non-beating heart, while the rest of the body continues to receive life-sustaining nourishment through the machine. In contrast, off-pump CABG does not require a heart-lung bypass machine and does not involve the stopping of the heart.

All patients who undergo CABG have a detour created that bypasses blockages within the coronary arteries. This gives it the name “coronary artery bypass graft surgery.” Patients may also undergo a “cardiopulmonary bypass,” which provides a route for blood to flow away from the lungs and heart, making the CABG procedure safer and more straightforward. This latter approach is employed in off-pump bypass surgery, with a blood vessel from one part of the body employed in bypassing the blocked coronary artery.

One reason surgeons developed off-pump bypass techniques is that on-pump CABG has demonstrated drawbacks: Its inflammatory effects are associated with gastrointestinal distress, renal dysfunction, and cardiac abnormality. In the 2005 paper “On-Pump Beating Heart versus Off-Pump Coronary Artery Bypass Surgery,” Dr. Hartmuth Bittner and his coauthors found that those who underwent off-pump CABG had a slightly shorter total length of ICU stay, along with reduced postoperative inotropic support needs. There was no significant difference in morbidity between the two groups.

The authors did reference a study that, unlike theirs, identified elevated levels of oxidative stress among patients who underwent on-pump heart surgery. They speculated that this related to the arresting of the heart. The authors also found slightly increased myocardial injury among on-pump CABG patients, concluding that, for routine coronary patients, off-pump CABG presented the better option.

A 2014 study titled “On Pump Coronary Artery Bypass Graft Surgery versus Off Pump Coronary Artery Bypass Graft Surgery: A Review” employed an extensive literature search. It found that on-pump CABG resulted in “significantly higher frequencies of complete revascularization” compared with the off-pump method. Incomplete revascularization is associated with increased mortality in the long term, a higher prevalence of recurrent angina, and more repeat procedures.

However, on-pump bypass had much higher post-operative morbidity rate overall than off-pump bypass. This was largely attributable to increased systemic inflammatory responses and the cardiopulmonary bypass process itself. Off-pump CABG is a shorter procedure, with short-term morbidity and mortality reductions particularly noticeable in very high-risk patients.

The 2022 paper “Ten-Year Outcomes of Off-Pump vs On-Pump Coronary Artery Bypass Grafting in the Department of Veterans Affairs: A Randomized Clinical Trial” reported a slightly reduced revascularization-free survival among off-pump group patients. However, for most patients, traditional on-pump and off-pump CABG options presented nearly the same long-term outcomes.

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Causes, Symptoms, and Treatment of Lung Hernias

Hernias are typically associated with the intestine pushing through a tear in the abdomen’s muscle wall, as when lifting a heavy object causes strain. However, hernias can also be associated with the lungs. With a lung hernia, a portion of the lung bulges through a weak spot, or pushes through a tear, in the chest wall or neck passageway.

A relatively uncommon condition, lung hernia reflects factors such as surgery, trauma, or an underlying medical issue. Associated with 80 percent of cases, hernias with trauma as the cause typically result from blunt force injuries such as falls and car accidents. Surgical lung hernias reflect weakness caused by past lobectomies, pneumonectomies, and other thoracic surgeries.

In extremely rare cases, there is no discernible traumatic cause for the hernia. In these cases, issues such as emphysema and chronic obstructive pulmonary disease (COPD), which weaken the thoracic wall over time, are implicated. Other potential causes include chronic use of steroids and a series of harsh, sharp coughs, which can open an old incision or tear a chest muscle.

While sometimes serious, lung hernias are not life threatening in and of themselves, and they are relatively easy to identify, diagnose, and treat. Symptoms include shortness of breath, challenges breathing deeply, and sharp pains associated with coughing, sneezing, and inhaling. Swelling or general soreness in a particular chest region may also be present.

Treating mild to moderate lung hernias often involves basic measures such as cough suppressants, infection and analgesic pain medications, and bed rest. Surgery is recommended for larger and more severe hernias, with surgeons returning the lung to its proper position. The opening is then stitched up and the weakened region of the chest reinforced.

The 2020 paper “Pulmonary Herniation after Minimally Invasive Cardiac Surgery” examined how post-surgical complications can lead to hernias that result from chest wall trauma. The clinical researchers from the Kerckhoff Heart Center in Bad Nauheim and the Institute for Pharmacology and Preventive Medicine in Cloppenburg, Germany, found that lung hernias often occur near past thoracotomy sites. They become clinically visible in males when coughing occurs.

However, women’s clinical symptoms tended to be hidden by the breasts, and “unspecific complaints or occasional pain when coughing” is the most prevalent indicator. This makes prompt and early evaluations and referral to advanced diagnostics important in diagnosis.

In the 2023 paper “Surgical Repair of Spontaneous Lung Herniation Induced by Vigorous Coughing,” researchers examined the case of a 72-year-old male with a background of smoking, arterial hypertension, and COPD. With no reported history of trauma, he experienced spontaneous lung herniation as a result of vigorous coughing.

Chest X-rays and CT scans helped identify the scope of the issue, with pulmonary function tests indicating restricted airflow and reduced lung capacity. Open surgical repair was performed, with thoracotomy successfully resolving chest pain and shortness of breath. Post-surgery, the patient embarked on intensive physiotherapy. He also received respiratory therapy and pharmacotherapy for his underlying COPD issue.

As a result, the patient was asymptomatic and free of pain, with no daily activity limitations, three months after the procedure. The authors attributed this positive result in a potentially serious spontaneous lung hernia case to a combination of early recognition and prompt treatment.

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Advances in Lung Transplantation

Lung transplantation has evolved over the years, improving patient outcomes and expanding donor criteria. The introduction of the lung allocation system (LAS) has prioritized patients by urgency and benefits. The LAS uses a complex algorithm to match donors and recipients by considering age, lung function, medical condition, and post-transplant survival for better results.

Over 60 percent of lung transplant centers have adopted the LAS. This system has significantly reduced wait-list mortality. The LAS has been beneficial to patients with chronic lung conditions.

The criteria for donors have also expanded over the years and include accepting smokers, older donors, and donors from cardiac death. This has increased the number of patients who can receive transplants.

New approaches include extracorporeal life support (ECLS), a device that takes the place of the lungs and heart and offers cardiopulmonary support. The ECLS has enhanced the outcome for patients with severe respiratory failure, although adverse effects may include bleeding and infection.

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Minimally Invasive Cardiac Surgery

In minimally invasive cardiac surgery, surgeons make only a small incision in the chest to access the heart. This approach allows multiple heart treatments without cutting through the breastbone, as in traditional open-heart surgery. The minimally invasive method offers several benefits.

Minimally invasive techniques can manage various cardiac conditions, such as atrial septal defect, atrioventricular septal defect, and mitral regurgitation. In some cases, a surgeon passes a tiny video camera and other instruments through the small incision to seal defects, remove growths, or repair or replace heart valves. The surgeon operates from a console, precisely manipulating the camera and instruments. This technique minimizes blood loss, reduces the risk of infection and scarring, lessens postoperative pain, and accelerates healing time.

After surgery, most patients go to the intensive care unit for overnight monitoring. They may receive fluids, medications, and oxygen. The typical hospital stay is a few days, during which the healthcare team monitors vital signs, administers pain medication, and provides instructions for postoperative care. Upon discharge, patients may need to follow specific measures to promote heart health, such as maintaining a healthy diet, exercising, reducing stress, and quitting smoking.

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The World’s First Heart Pump Implant and Kidney Transplant Surgery

Surgeons from New York’s NYU Langone Health have performed the world’s first successful combined heart pump implant and kidney transplant surgery. The first-of-its-kind procedure was the first documented case of a person with a heart pump implant receiving an organ transplant.

Lisa Pisano, 54, of New Jersey, was diagnosed with heart failure, which was complicated by an end-stage kidney disease. She has been on dialysis for quite some time, which makes her condition unsuitable for a heart or a kidney transplant. The doctors discussed the procedure with Pisano, which included two separate surgeries: the first phase will be inserting a left ventricular assist device (LVAD), and the second phase will be the gene-edited pig kidney transplant.

According to the doctors, Pisano’s high levels of antibodies would have made it difficult to find a match for a kidney transplant. However, the doctors have ruled out that the high antibody levels were neither harmful to gen-edited pig kidneys. Also, LVADs are typically not given to patients on dialysis because of the high incidence of mortality among dialysis patients with heart pumps. However, since Pisano is receiving a gene-edited pig kidney, the doctors gave it a go after the two-step procedure was cleared by NYU Langone’s review board and the FDA’s “compassionate use” program.

The doctors said Pisano was recovering well after the combined surgeries performed on April 4 and April 11. Medical experts look forward to the day animal organ transplantation into humans will significantly help organ supply.

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A Brief Overview of Circumstances that Necessitate Heart Surgery

Heart, cardiac, and cardiovascular surgery refers to any surgery involving the heart or connected blood vessels. Surgeons perform such operations to treat complications of ischemic heart disease (IHD), abnormal heart rhythms, and congenital heart disease (CHD).

Ischemic heart disease or coronary artery disease leads to reduced blood flow to the cardiac muscle due to atherosclerotic plaque build-up in the heart’s arteries. IHD remains the most common cardiovascular disease. Individuals may experience various symptoms, such as chest pain or discomfort that travels to the arm, shoulder, back, jaw, or neck. IHD types include unstable angina, stable angina, and myocardial infarction.

Congenital heart defect or congenital heart anomaly stems from birth defects that affect the heart's structure or critical vessels. A cardiovascular disease, CHD has varied signs and symptoms based on the specific defect type. Moreover, some symptoms pose life-threatening risks while others do not. Therefore, individuals benefit from annual checkups to monitor risk and progress.

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An Overview of Atrial Fibrillation

Atrial fibrillation (AFib) refers to an irregular and rapid heart rhythm that increases the risk of serious conditions such as blood clots in the heart, heart failure, stroke, and other serious medical conditions. During atrial fibrillation, the heart’s upper chambers, also known as the atria, begin to beat irregularly and out of sync with the lower heart chambers (ventricles). Usually, the electrical signals that trigger the heart to jump start the process in the sinoatrial node, an area in the upper right heart chamber that causes both the right and left atrium to contract.

The contraction then pumps blood to lower heart chambers causing the signals travel further down the heart making the ventricles to contract, However in AFib, the electrical signaling system malfunctions which causes irregular/unusual electrical signals in the upper heart chamber that disrupts the entire blood pumping process. This is because abnormal signals cause irregular contraction of the heart's upper chambers, thus making the atria and ventricles unable to pump blood as they should.

Even though AFib may not have symptoms, some people experience a fast and pounding heartbeat, light-headedness, and shortness of breath. Atrial fibrillation is classified into three main types: Paroxysmal AFib which lasts less than a week and ceases on its own without medical intervention, Persistent AFib which takes more than a week and requires medical treatment, and long-standing persistent AFib which lasts over a year and can be challenging to treat. Some of the common risk factors that cause AFib include high blood pressure and coronary heart disease.

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How Technology Is Changing Surgical Procedures

Modern technology has become common in the health care industry and is rapidly changing surgical procedures. More and more, medical professionals are leveraging emerging technologies to improve the quality of surgeries.

Robotic assistance is one of the top ways technology is changing surgery. In the past two decades, there has been a significant increase in robotics-assisted surgeries. Robotics is gaining acceptance in various surgical specialties, including cardiology, urology, gynecology, and orthopedics. Notable benefits of robotics-assisted surgery include increased precision and stability.

Artificial intelligence (AI) and machine learning are also changing surgical procedures. This technology has many applications in improving surgical diagnostics and operation accuracy. AI algorithms can analyze real-time surgical data for optimal diagnoses and treatment planning. In machine learning, algorithms can look at historical patterns of surgical procedures to predict the likely outcome of an operation and the risk of complications. These technologies can effectively help to improve the outcome of modern surgery.

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Smoking Is the Biggest Risk Factor in Heart Disease

Smoking is the cause of one-fifth of all heart disease-related deaths in the United States every year. That is about 80,000 deaths attributable to smoking, making it the greatest risk factor for sudden cardiac death. People who smoke are up to four times more likely to have sudden cardiac death than nonsmokers.

Smoking increases the risk of heart disease because it makes the heart beat faster, harder, and irregularly and reduces the amount of oxygen in the blood. Even secondhand smoke is dangerous. Simply inhaling tobacco smoke decreases the flow of oxygen to the heart and increases blood pressure, fat build-up in arteries, and blood clotting and raises the risk of lung disease and blood vessel damage.

Doctors ask patients to quit smoking to reduce their risk of chronic illness. People who quit smoking prolong their lives, feel healthier, look better, and enhance their senses of taste and smell.

Individuals who want to quit smoking should pick a date to quit and commit to it. To strengthen their resolve, they should list their reasons for quitting, go over them regularly, avoid places where smoking is allowed, avoid things that trigger smoking, and avoid spending time with smokers. Joining a smoking cessation group also helps.

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Cardiac Arrest First Aid to Note

Cardiac arrest is a heart condition where the heart suddenly stops beating and pumping blood to other parts of the body. Every year, the United States records about 356,000 out-of-hospital cardiac arrests. About 60 to 80 percent of these cardiac arrest victims die upon reaching the hospital.

Consequently, people must be familiar with the measures or steps to take when someone around them is down with cardiac arrest. One of the first measures to take when someone goes down due to cardiac arrest is to call 911 or any local emergency number that might apply.

While waiting for an emergency vehicle, you should try administering CPR to the patient. If you are not skilled at general CPR, you can administer hands-on CPR. Hand-only CPR involves pressing on the patient's chest in a hard and fast motion. Doing this about 100 to 120 times within a minute can help the heart pump again until you can access a defibrillator.

Upon accessing a defibrillator, you can continue administering CPR while the other person attaches the defibrillator's pads to the patient's chest. The first pad should be attached to the patient's collarbone on the upper right side, while the second pad should be attached to the patient's left side just by the elbow. The defibrillator helps to get the heart pumping faster before you get professional medical attention.

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Technology Innovations Improving Cardiac Treatment

For over three decades, Dr. Hartmuth Bittner has focused on treating patients suffering from various cardiac ailments. He successfully performed the first lung transplant in Central Florida at Florida Hospital in Orlando. At Cardiac Surgery Associates, Dr. Hartmuth Bittner leverages technology to provide patients with the best cardiac treatment options. Technology has revolutionized cardiac care, allowing cardiologists and cardiac surgeons to explore improved treatment options. New technologies facilitate early detection and boost care for critically ill patients, providing better outcomes. The following are some of the technologies impacting cardiac care and treatment. Use of Personalized Heart Models University of London scientists have designed 3D prints of heart models based on scans of children with congenital heart disease. These patient models help doctors explain a heart disorder to patients using easier-to-understand approaches than traditional medical imaging techniques such as echocardiograms. Skin Patch to Mitigate Strokes Researchers from the University of Nottingham have pioneered a skin patch designed for ambulance emergency responders who need to treat stroke patients. The patch administers glyceryl trinitrate, which widens blood vessels and reduces blood pressure, lowering stroke damage. Administering prompt treatment within an hour after a stroke helps to improve outcomes. Nanomaterials to Reduce Cholesterol Scientists continue researching how nanomaterials can assist in delivering drugs that lower cholesterol levels. University of Surrey researchers have embarked on developing nanomaterials, testing them, and verifying their effectiveness. If successful, nanomaterials will become an alternative for patients with allergic reactions to statins.

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The American Health Council’s “Best in Medicine” Award

An accomplished physician who specializes in cardiothoracic surgery and vascular surgery, Dr. Hartmuth Bittner is one of 36 specialty doctors that offer comprehensive medical care to patients of Cardiac Surgery Associates. In 2017, Dr. Hartmuth Bittner was selected and featured by the American Health Council (AHC) in its “Best in Medicine” and “Leader in Medicine” lists. AHC is the only organization in the US with a membership that represents all sectors of the healthcare industry. AHC strives to recognize and support outstanding individuals and institutions who make a difference in the quality of their patients’ lives. Every year, AHC recognizes the significant contribution of America’s best doctors in the field of medicine, and features them in its “Best in” web platform. The “Best in Medicine” award is given to selected physicians from all 50 states who have contributed towards the betterment of healthcare. The same doctors can be selected to a higher award of “Leaders in Medicine” or “Award of Excellence.” AHC’s Research Department and Nomination Committee handles the awards’ nomination and selection processes. Nominees are identified using publicly available information from sources such as healthcare associations, medical practice registrations, and medical school alumni directories. The profiles of nominees are compiled using open-source intelligence. From the information gathered, a score is assigned using a weighted algorithm. Nominees are interviewed to verify the information and the scores, and to know the candidates’ motivations for the good of healthcare.

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Causes and Symptoms of Aortic Aneurysms

A physician in Lafayette, Indiana, Dr. Hartmuth Bittner, delivers minimally invasive treatment for cardiothoracic diseases. In addition, Dr. Hartmuth Bittner focuses on performing surgeries that repair aortic aneurysms.

The aorta stands as the largest blood vessel in the body. With its branches, the aorta transports oxygen-rich blood from the heart into the brain and the extremities. The thick aorta walls accommodate normal ranges of blood pressure. However, traumatic events and genetic conditions can lead to damaged or weakened vessel walls. The constant force of blood pushing through the vessel wall can ultimately result in an aneurysm.

Two areas present the highest likelihood of aortic aneurysms: abdominal and chest. The most common abdominal type impacts the stomach area, while thoracic aortic aneurysms occur in the chest area above the diaphragm. As blood surges through tears in the aortic wall, the aorta’s inner and middle layers separate or dissect, leading to uncontrollable hemorrhages and potentially rapid mortality.

Around 75 percent of abdominal aortic aneurysms result from smoking combined with high blood pressure, elevated cholesterol, and hardened arteries. Most individuals impacted by aortic aneurysm risks do not present obvious symptoms, such as the balloon-like bulges that define the condition until the aorta tears. The United States Preventive Services Task Force has recommended that males between 65 and 75 years old who have smoked at some point in their lives undergo an abdominal aortic aneurysm ultrasound screening.

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General Antibiotic Dosage Protocol for Heart Surgery

A seasoned cardiothoracic surgeon board certified by the American Board of Thoracic Surgery, Dr. Hartmuth Bittner practices through Cardiac Surgery Associates in Lafayette, Indiana. Dr. Hartmuth Bittner has also garnered several awards and accolades throughout his career, and is recognized as one of the nation’s leading heart surgeons.

After undergoing heart surgery, preventing infections becomes a critical concern, especially because an infection in the area of the surgical wound can become life-threatening. One significant measure involves administering preventive antibiotics. Surgical teams provide heart surgery patients with antibiotics about an hour before the surgery starts. This approach aims to shield patients from potential infections by killing harmful bacteria. Without prevention, these infections can develop and present signs in the skin or muscle tissues within one to three months after surgery.

Heart surgery patients may continue to receive antibiotics through an intravenous route both before and some hours after their surgery. This ensures patients are free from bacterial infection risks during these hours.

Most heart surgery patients also receive another dose of antibiotics around 24 hours after surgery. Limiting the antibiotics to a total of three doses, spaced roughly eight hours apart, prevents overuse. Antibiotic overuse causes antibiotic resistance, an issue where antibiotics become less effective over time.