Advancements of Off-Pump Surgery

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Dr. Costantini is a Cardiothoracic/Thoracic Surgeon at Broward Health Medical Center.

Dr. Costantini quickly gained national attention as the physician who cared for the infamous "Stingray Jim" Bertakis.

Bertakis was enjoying a leisurely cruise down a Florida canal when out of the water flew a 36-inch, 32-pound spotted eagle ray, that slammed into him from the blind side.  Its  "stinger" plunged into Jim's chest,  piercing his lung, then snapping off, leaving two inches of  the venomous, razor sharp and serrated barb inside of him. Only two other people in recorded medical history have survived a stingray barb to the heart area -  they were both 35 years old or younger.  At the time of his attack, Bertakis was 81. 

Because of the excellent care and treatment from Dr. Costantini, Bertakis made a full recovery.

For more information or to contact Dr. Costantini, call 954-776-0820.

About Coronary Artery Bypass Graft Surgery (CABG)

(CAB, Open Heart Surgery, Bypass Surgery)

Procedure Overview

What is coronary artery bypass surgery?

Coronary artery bypass graft surgery (CABG) is a procedure used to treat coronary artery disease in certain circumstances. Coronary artery disease (CAD) is the narrowing of the coronary arteries (the blood vessels that supply oxygen and nutrients to the heart muscle), caused by a buildup of fatty material within the walls of the arteries. This buildup causes the inside of the arteries to become rough and narrowed, limiting the supply of oxygen-rich blood to the heart muscle.

One way to treat the blocked or narrowed arteries is to bypass the blocked portion of the coronary artery with another piece of blood vessel. Blood vessels, or grafts, used for the bypass procedure may be pieces of a vein taken from the legs or an artery in the chest. One end of the graft is attached above the blockage and the other end is attached below the blockage. Thus, the blood is rerouted around, or bypasses, the blockage through the new graft to reach the heart muscle. This bypass of the blocked coronary artery can be done by performing coronary artery bypass surgery.

Traditionally, in order to bypass the blocked coronary artery in this manner, the chest is opened in the operating room and the heart is stopped for a time so that the surgeon can perform the bypass. In order to open the chest, the breastbone (sternum) is cut in half and spread apart. Once the heart is exposed, tubes are inserted into the heart so that the blood can be pumped through the body during the surgery by a cardiopulmonary bypass machine (heart-lung machine). The bypass machine is necessary to pump blood while the heart is stopped and kept still in order for the surgeon to perform the bypass operation.

While the traditional "open heart" procedure is still performed and often preferred in many situations, newer, less invasive techniques have been developed to bypass blocked coronary arteries. "Off-pump" procedures, in which the heart does not have to be stopped, were developed in the 1990's. Other minimally-invasive procedures, such as key-hole surgery (performed through very small incisions) and robotic procedures (performed with the aid of a moving mechanical device),?increasingly are being used.
Two other surgical improvements for persons undergoing CABG are endoscopic vein harvesting and endoscopic radial artery harvesting. In both of these procedures surgeons use an endoscope (thin surgical tube with a light and camera on the end) to locate blood vessels that will be used for bypassing the blocked coronary arteries. Veins are generally harvested from the inner thigh and calf areas of the legs, while the radial artery is harvested from the wrist.

Traditional (open) approaches involve making long surgical incisions down the inner thigh and/or calf. Research comparing traditional approaches with endoscopic methods indicates that patients generally have fewer complications, less leg pain, and shorter hospital stays with the endoscopic harvesting methods. Some persons, however, may not be eligible for these methods because of other health conditions.

Other related procedures that may be used to assess and/or treat the heart include resting or exercise electrocardiogram (ECG), Holter monitor, signal-averaged ECG, cardiac catheterization, chest x-ray, computed tomography (CT scan) of the chest, echocardiography, electrophysiological studies, magnetic resonance imaging (MRI) of the heart, myocardial perfusion scans, percutaneous transluminal coronary angioplasty (PTCA), radionuclide angiography, and ultrafast CT scan. Please see these procedures for additional information.

Coronary arteries of the heart:

To better understand how coronary artery disease affects the heart, a review of basic heart anatomy and function follows.

The heart is basically a pump. The heart is made up of specialized muscle tissue, called the myocardium. The heart's primary function is to pump blood throughout the body, so that the body's tissues can receive oxygen and nutrients and have waste substances taken away.

Like any pump, the heart requires fuel in order to work. The myocardium requires oxygen and nutrients, just like any other tissue in the body. However, the blood that passes through the heart's chambers is only passing through on its trip through the body - this blood does not give oxygen and nutrients to the myocardium. The myocardium receives its oxygen and nutrients from the coronary arteries. The coronary arteries lie on the outside of the heart and supply oxygenated blood to the heart tissue.

When the heart tissue does not receive an adequate blood supply, it cannot function as well as it should. If the myocardium's blood supply is decreased for a length of time, a condition called ischemia may develop. Ischemia can decrease the heart's pumping ability, because the heart muscle is weakened due to a lack of food and oxygen.

For many years, coronary artery disease (CAD) was commonly called "hardening of the arteries" and was not easily treated. However, in the last 30 years, many advances have been made in the diagnosis and treatment of cardiac diseases.

Reasons for the Procedure:

Coronary artery bypass surgery is performed to treat a blockage or narrowing of one or more of the coronary arteries, thus restoring the blood supply to the heart muscle.

Symptoms of coronary artery disease may include, but are not limited to, the following:

•    chest pain
•    fatigue
•    palpitations
•    shortness of breath

Unfortunately, there may be no symptoms of early coronary artery disease, yet the disease will continue to progress until sufficient artery blockage exists to cause symptoms and problems. If the blood supply to the heart muscle continues to decrease as a result of increasing obstruction of a coronary artery, a myocardial infarction, or heart attack, may occur. If the blood flow cannot be restored to the particular area of the heart muscle affected, the tissue dies.

There may be other reasons for your physician to recommend coronary artery bypass surgery.
Generally, a coronary artery bypass surgery follows this process:

1.    You will be asked to remove any jewelry or other objects that may interfere with the procedure.
2.    You will be asked to remove your clothing and will be given a gown to wear.
3.    You will be asked to empty your bladder prior to the procedure.
4.    An intravenous (IV) line will be started in your arm or hand. Additional catheters will be inserted in your neck and wrist to monitor the status of your heart and blood pressure, as well as for obtaining blood samples. Alternate sites for the additional catheters include the subclavian (under the collarbone) area and the groin.
5.    You will be positioned on the operating table, lying on your back.
6.    The anesthesiologist will continuously monitor your heart rate, blood pressure, breathing, and blood oxygen level during the surgery. Once you are sedated, a breathing tube will be inserted through your throat into your lungs and you will be connected to a ventilator, which will breathe for you during the surgery.
7.    A catheter will be inserted into your bladder to drain urine.
8.    The skin over the surgical site will be cleansed with an antiseptic solution.
9.    Once all the tubes and monitors are in place, incisions may be made in one or both of your legs or one of your wrists to obtain a section of vein to be used for grafts.
10.    The physician will make an incision (cut) down the center of the chest from just below the Adam's apple to just above the navel.
11.    The sternum (breastbone) will be divided in half with a special operating instrument. The physician will separate the two halves of the breastbone and spread them apart to expose the heart.



Eugene Costantini

Eugene Costantini, MD

Cardiothoracic Surgeon

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