Heart Bypass Surgery in India and UAE | Complete Patient Guide

• ELIGIBLE CANDIDATES:

• Patients with triple-vessel coronary artery disease (CAD affecting the LAD, LCx, and RCA) confirmed on coronary angiography

• Patients with significant left main coronary artery stenosis (≥50% blockage), regardless of symptom severity

• Patients with two-vessel CAD involving the proximal LAD with reduced left ventricular ejection fraction (LVEF <50%)

• Patients with diabetes mellitus and multi-vessel CAD, where CABG demonstrates superior long-term outcomes over PCI (per FREEDOM trial evidence)

• Patients who have experienced in-stent restenosis or failed prior PCI

• Patients with stable angina refractory to optimal medical therapy

• Patients requiring concomitant cardiac surgery (e.g., valve repair/replacement, correction of left ventricular aneurysm)

• Patients with a SYNTAX Score >33, indicating complex coronary anatomy better suited to surgical revascularization

• REQUIRED PRE-OPERATIVE DIAGNOSTICS:

• Coronary angiography (diagnostic gold standard for lesion characterization)

• Echocardiogram (transthoracic or transesophageal) to assess LVEF, wall motion abnormalities, and valve function

• 12-lead ECG and 24-hour Holter monitoring

• CT Coronary Angiography (CTCA) or Fractional Flow Reserve (FFR) measurement for functional lesion assessment in selected cases

• Nuclear Myocardial Perfusion Imaging (MPI) or Cardiac MRI for viability assessment in patients with reduced LVEF

• Full blood workup: CBC, renal function panel (eGFR, creatinine), liver function tests, coagulation profile (PT/INR, aPTT), HbA1c, lipid panel, and thyroid function

• Carotid Doppler ultrasound to rule out concomitant carotid artery disease prior to surgery

• Pulmonary function tests (PFTs) in patients with a smoking history or known respiratory disease

• Peripheral vascular assessment for conduit vessel suitability (saphenous vein mapping, radial artery Allen test)

• RELATIVE CONTRAINDICATIONS:

• Severely impaired renal function (eGFR <30 mL/min) — requires nephrological co-management and careful perioperative planning

• Active systemic infection or endocarditis (surgery deferred until resolved)

• Severely reduced LVEF (<25%) without evidence of viable myocardium on imaging

• Uncorrectable coagulopathy or active bleeding disorder

• Prohibitive frailty or major comorbidities conferring excessively high operative risk (EuroSCORE II >10% may prompt Heart Team discussion regarding TAVI, TAVR, or palliative care alternatives)

• Recent large myocardial infarction (typically surgery deferred 3–4 weeks to allow myocardial stabilization, unless emergent)

STANDARD ON-PUMP CABG (Conventional):

The most widely performed technique, in which the heart is temporarily arrested using cardioplegic solution and the patient is placed on a cardiopulmonary bypass (CPB) machine — a heart-lung machine that maintains systemic circulation and oxygenation during surgery. This approach provides a still, bloodless operative field, allowing precise anastomosis construction. Typical operative time is 3–5 hours. Conduits used include the LIMA (gold standard for LAD bypass), saphenous vein grafts (SVGs) for right and circumflex territories, and radial artery grafts for patients requiring total arterial revascularization.

OFF-PUMP CABG (Beating-Heart Surgery):

The bypass grafts are constructed while the heart continues beating, eliminating the risks associated with CPB such as systemic inflammatory response, neurological microemboli, and pump-related coagulopathy. Stabilization devices (e.g., Octopus tissue stabilizer, Starfish heart positioner) immobilize the target coronary segment. Off-pump CABG is particularly advantageous in patients with heavily calcified aortas (reducing stroke risk), impaired renal function, or significant pulmonary disease. Not all coronary anatomies are accessible via this technique, and a conversion to on-pump surgery may be required in 2–5% of cases.

MINIMALLY INVASIVE DIRECT CORONARY ARTERY BYPASS (MIDCAB):

Performed through a small left anterior thoracotomy (4–5 cm incision) without full sternotomy and without CPB. Primarily used for isolated LAD disease using the LIMA as the conduit. Advantages include reduced surgical trauma, minimal blood loss, shorter hospital stay, faster return to activity, and superior cosmetic outcome. Often combined with PCI to non-LAD vessels in a Hybrid Coronary Revascularization (HCR) strategy — offering a tailored approach for selected multi-vessel CAD patients.

ROBOTIC-ASSISTED CABG:

Available at select advanced cardiac centers in both India and the UAE, robotic CABG employs the da Vinci Surgical System to harvest the LIMA and construct anastomoses through small port incisions (typically 8–12 mm). The robotic platform provides 3D magnified visualization, enhanced instrument dexterity (7 degrees of freedom), and elimination of physiologic tremor — enabling precise suturing in anatomically challenging locations. Robotic CABG offers the benefits of MIDCAB with even smaller incisions and is suitable for carefully selected patients with good cardiac function and accessible target vessels.

HYBRID CORONARY REVASCULARIZATION (HCR):

A staged or simultaneous combination of MIDCAB (for the critical LIMA-to-LAD graft) and PCI (for non-LAD lesions), performed in a hybrid operating room equipped with both surgical and catheterization laboratory capabilities. This approach maximizes the durability of the most important graft (LIMA-LAD) while avoiding full sternotomy for less complex vessels. Ideal for patients with multi-vessel CAD who are poor candidates for conventional CABG due to comorbidities.

TOTAL ARTERIAL REVASCULARIZATION:

An advanced strategy utilizing bilateral internal mammary arteries (BIMA) and/or radial artery grafts exclusively — avoiding saphenous vein grafts entirely. Superior long-term patency rates (bilateral IMA grafts demonstrate >95% patency at 10 years) and reduced need for repeat revascularization. Increasingly favored in younger patients (<70 years) and those with longer life expectancy. Requires careful patient selection to minimize risk of sternal wound complications associated with bilateral IMA harvesting, especially in diabetic or obese patients.

KEY TECHNOLOGIES SUPPORTING SURGICAL DECISION-MAKING:

• Fractional Flow Reserve (FFR) and instantaneous wave-free ratio (iFR) for functional lesion assessment

• Intraoperative transit-time flow measurement (TTFM) to verify graft patency immediately after construction

• Intraoperative transesophageal echocardiography (TEE) for real-time cardiac monitoring

• Epiaortic ultrasound scanning to identify aortic atheroma and guide cannulation strategy

• Enhanced Recovery After Cardiac Surgery (ERAS Cardiac) protocols to minimize complications and shorten hospital stay

PHASE 1 — PRE-ARRIVAL PLANNING (2–4 weeks before travel):

• GAF Healthcare receives patient medical records (angiography reports, echocardiogram, blood work, prior cardiac history)

• Case is reviewed by a panel of senior cardiac surgeons and interventional cardiologists at the partner hospital

• A detailed Second Opinion Report and individualized treatment plan is issued, including recommended surgical approach, estimated cost, and timeline

• e-Medical Visa (India) or Entry Visa (UAE) application assisted by GAF Healthcare's visa coordination team

• Flight arrangements, airport transfers, and accommodation for patient and one attendant are confirmed

PHASE 2 — ARRIVAL & PRE-OPERATIVE WORKUP (Days 1–3):

• Airport pickup in a dedicated medical transport vehicle

• Hospital admission and orientation by a GAF Healthcare patient coordinator (who accompanies through the entire stay)

• Pre-operative diagnostic confirmation: repeat ECG, echocardiogram, chest X-ray, full blood panel, anesthesia assessment, pulmonary function review

• Cardiology and cardiac surgery consultations; anesthesiologist visit and pre-op counseling

• Optimization of existing medications (bridging anticoagulation if applicable; discontinuation of antiplatelet agents per protocol)

• Patient and family education session covering procedure details, ICU stay, rehabilitation plan, and discharge goals

PHASE 3 — SURGERY DAY (Day 3–4):

• Patient shifted to the operating theater; general anesthesia induced; TEE probe placed for intraoperative monitoring

• Sternotomy (or minimally invasive incision) performed; conduit vessels harvested simultaneously by a second surgical team

• Cardiopulmonary bypass initiated (on-pump) or stabilization device deployed (off-pump); target coronary arteries identified and grafts anastomosed

• Intraoperative TTFM performed to confirm each graft is functional before chest closure

• Surgical time: typically 3–5 hours depending on number of grafts and technique

• Patient transferred to the Cardiac ICU (CICU) for immediate post-operative monitoring

PHASE 4 — CARDIAC ICU RECOVERY (Days 1–2 Post-Op):

• Continuous hemodynamic monitoring (arterial line, central venous pressure, Swan-Ganz catheter in selected cases)

• Mechanical ventilation weaning and extubation targeted within 4–8 hours of surgery (fast-track cardiac anesthesia protocol)

• Chest drain management; early ambulation initiated as soon as hemodynamics permit

• Pain management via multimodal analgesia (parasternal nerve blocks, IV analgesia, transitioning to oral medications)

• Commencement of post-operative cardiac medications: aspirin, statin, beta-blocker, ACE inhibitor

PHASE 5 — STEP-DOWN WARD RECOVERY (Days 3–7):

• Transfer from CICU to a monitored cardiac step-down unit

• Progressive ambulation: short walks by day 3, increasing distance daily

• Physiotherapy-led deep breathing exercises and incentive spirometry to prevent pulmonary complications

• Wound care and assessment of sternal and harvest site healing

• Dietary counseling (low-sodium, heart-healthy diet) and diabetes management optimization

• Repeat echocardiogram prior to discharge to confirm cardiac function

• Patient and caregiver discharge education: wound care, activity restrictions, medication adherence, red-flag symptoms

PHASE 6 — IN-COUNTRY RECUPERATION (Weeks 2–4):

• Patient discharged to hotel/serviced apartment accommodation arranged by GAF Healthcare (within 15–20 minutes of the hospital)

• Outpatient follow-up consultations at weeks 2 and 4 (wound check, ECG, blood tests, medication review)

• Cardiac rehabilitation sessions begin in weeks 2–3 at the hospital's outpatient rehabilitation center (supervised exercise, education, psychosocial support)

• Sternal precautions maintained: no lifting >2 kg, no driving, no reaching overhead — typically for 6–8 weeks total

PHASE 7 — FIT-TO-FLY ASSESSMENT & DEPARTURE (Week 4–6):

• Formal medical fitness-to-fly assessment by the treating cardiac surgeon and cardiologist (minimum 4 weeks post-surgery for uncomplicated CABG)

• Medical summary, discharge records, operative report, and medication prescriptions prepared in English for the patient's home physician

• Business class or lie-flat seating recommended for long-haul flights; compression stockings and in-flight hydration guidance provided

• GAF Healthcare coordinates airport transfer and ensures patient is accompanied or safely escorted to departure gate

PHASE 8 — LONG-TERM FOLLOW-UP:

• Remote follow-up consultations via telemedicine at 3 months, 6 months, and 1 year post-surgery

• Continued cardiac rehabilitation at home

• Annual cardiology review recommended; coronary CT angiography at 5 years to assess graft patency

• Strict secondary prevention: lifelong aspirin, statin therapy, blood pressure and diabetes control, smoking cessation, and structured exercise program