Post-Bypass Surgery: Why Am I Still Experiencing Chest Pain and Breathlessness?

Q: Post-Bypass Surgery: Why Am I Still Experiencing Chest Pain and Breathlessness?

Hello： Coronary artery bypass grafting (CABG) is, as the name suggests, a procedure that bridges a blood vessel from the aorta to the distal end of the coronary artery, "bypassing" the obstructed lesion to ensure adequate blood supply to the myocardium downstream. <br>Typically,

After coronary bypass surgery, I still feel chest tightness and shortness of breath, worse than before the surgery?

Hello, Dr.
Huang! My brother underwent a cardiac catheterization due to chest tightness, which revealed 50% blockage at the ostium of the left main coronary artery (LM), 70% blockage in the mid-segment of the left anterior descending artery (LAD) (the most severe), 50% blockage at the ostium of the right coronary artery (RCA), and additional blockages in the distal RCA and left circumflex artery (LCx).
He subsequently had a bypass surgery performed by the cardiothoracic surgery department at FE Hospital.
The discharge summary noted the procedure as OPCAB x 4 (LIMA to LAD; RIMA to GSV to diagonal branch to PDA to distal RCA).
However, the accompanying diagram indicated that while the LIMA was connected to the LAD, it appeared to connect at the proximal end near the LM rather than the distal end of the blockage, and there was no record or diagram showing the connection for the LCx.
It has now been four weeks post-surgery, yet he still frequently experiences chest tightness and shortness of breath (which improves with sublingual nitroglycerin).
He becomes breathless after walking for just 20 minutes (compared to being able to walk for an hour pre-surgery) and feels worse than before the operation.
He also experiences occasional arrhythmias (as indicated by a blood pressure monitor) and an increased heart rate, along with dizziness.
I have spoken with several fellow patients who have undergone bypass surgery (including those I know from the ward and clinic, as well as three friends), and they all reported feeling much better after discharge without experiencing the aforementioned symptoms, nor did they require sublingual nitroglycerin.
I have been diligently using a lung function improvement device multiple times a day and participating in walking rehabilitation.
When I asked the doctor during a follow-up visit whether my bypass grafts were connected properly, the response was that they couldn't recall unless another cardiac catheterization was performed.
I am curious as to why I am experiencing these symptoms while others are not.
The doctor mentioned that everyone is different.
I would like to boldly inquire: based on the information provided, could it be that my bypass grafts were not connected properly, or could there be other factors at play? Why is there such a significant difference compared to other patients? Thank you.

Peng Ren, 60~69 year old female. Ask Date: 2019/05/08

Dr. Huang Yinghe reply Cardiology

Hello: Coronary artery bypass grafting (CABG) is, as the name suggests, a procedure that bridges a blood vessel from the aorta to the distal end of the coronary artery, "bypassing" the obstructed lesion to ensure adequate blood supply to the myocardium downstream.
Typically, the grafts are connected to the distal ends of the three major arteries: the left anterior descending artery (LAD), right coronary artery (RCA), and left circumflex artery (LCX).
However, due to individual variations in vascular anatomy, such as a small myocardial territory supplied by the LCX, it may not be necessary to perform a bypass on the LCX.
The left main coronary artery (LM) branches into the LAD and LCX, so the bypass surgery does not directly address the LM; the grafting to the LAD and LCX can supply blood flow to the anterior wall of the heart.
If you feel that your postoperative symptoms have not improved or have even worsened, it is advisable to first conduct non-invasive tests such as an electrocardiogram (ECG) and echocardiogram to check for signs of deteriorating cardiac function.
If there are indications of worsening function, it may be necessary to perform a cardiac catheterization to assess the status of the grafts (reports indicate that about 15-18% of grafts using the great saphenous vein (GSV) may become occluded within one month post-surgery).
Of course, there are many reasons for shortness of breath; if the surgical grafts are functioning well, other factors such as pulmonary disease, anemia, and endocrine issues may also need to be considered.
Wishing you safety, Chiayi Hospital, Huang Ying-He.

Reply Date: 2019/05/08

More Info

After undergoing bypass surgery, it is not uncommon for patients to experience ongoing symptoms such as chest pain and breathlessness. Your situation, as described, raises several important considerations that could help explain why you are still experiencing these symptoms despite the surgery.

First and foremost, it is essential to understand that bypass surgery aims to restore blood flow to the heart by creating new pathways around blocked arteries. However, the success of this procedure can vary significantly among individuals due to several factors, including the patient's overall health, the extent of heart disease, and the specific anatomy of the coronary arteries.

In your case, the fact that you are experiencing chest pain and breathlessness four weeks post-surgery could be attributed to several potential causes:
1. Incomplete Revascularization: While the surgery may have successfully bypassed the most critical blockages, it is possible that other areas of the coronary arteries remain narrowed or blocked. This can lead to inadequate blood supply to the heart muscle, resulting in symptoms similar to those experienced before the surgery. A follow-up angiogram may be necessary to assess the status of the bypass grafts and any remaining blockages.

2. Postoperative Healing: After heart surgery, the body undergoes a healing process that can sometimes cause discomfort or pain. The sternum, which is often cut during surgery, takes time to heal, and the surrounding tissues may also be inflamed. This can lead to sensations of tightness or pain in the chest, which may be mistaken for cardiac-related symptoms.

3. Cardiac Rehabilitation: Engaging in a structured cardiac rehabilitation program is crucial for recovery after bypass surgery. This program typically includes supervised exercise, education about heart-healthy living, and counseling to help manage stress and anxiety. If you have not yet participated in such a program, it may be beneficial to discuss this with your healthcare provider.

4. Anxiety and Stress: The experience of undergoing heart surgery can be traumatic, and many patients experience anxiety or depression afterward. These psychological factors can manifest as physical symptoms, including chest pain and breathlessness. It is important to address these emotional aspects of recovery, possibly with the help of a mental health professional.

5. Other Medical Conditions: Conditions such as gastroesophageal reflux disease (GERD), pulmonary issues, or even musculoskeletal pain can mimic cardiac symptoms. It is essential to consider these possibilities and discuss them with your healthcare provider.

6. Medication Side Effects: If you are taking medications post-surgery, some may have side effects that contribute to your symptoms. For example, certain blood pressure medications can cause dizziness or fatigue. Reviewing your medications with your doctor may help identify any potential issues.

Given the complexity of your symptoms and the variability in recovery experiences among patients, it is crucial to maintain open communication with your healthcare team. If your symptoms persist or worsen, it is advisable to seek further evaluation, which may include additional imaging studies or consultations with specialists such as a cardiologist or a cardiac surgeon.

In summary, while it is concerning to experience ongoing symptoms after bypass surgery, there are multiple potential explanations. A thorough evaluation by your healthcare team can help identify the underlying causes and guide you toward appropriate management strategies. Remember, recovery is a process, and it is essential to be patient with yourself as you navigate this journey.

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