Heart Bypass SurgeryBy
Sarah Lewis, PharmD
What is heart bypass surgery?
Heart bypass surgery, also called coronary artery bypass graft (CABG) surgery, is a treatment for coronary artery disease or atherosclerosis. Heart bypass surgery involves the creation of a new route for blood to flow around narrowed or blocked coronary arteries.
Your coronary arteries are the blood vessels that supply your heart muscle with blood. The newly created route is made with a graft. A graft is a healthy blood vessel taken from other places in your body.
Atherosclerosis is a common cause of narrowed or blocked coronary arteries. In atherosclerosis, fatty deposits build up on coronary artery walls and harden into a substance called plaque. As plaque builds on coronary artery walls, the artery narrows and hardens. A serious blockage can eventually occur. This reduces blood flow through the coronary artery.
Atherosclerosis can also cause a blood clot to form. A blood clot can completely block the coronary artery (heart attack).
Heart bypass surgery is a common but major surgery with significant risks and potential complications. You may have less invasive treatment options. Consider getting a second opinion about all your treatment choices before having heart bypass surgery.
Types of heart bypass surgery
Heart bypass surgery is named by the number of coronary arteries that are bypassed. Bypassing two coronary arteries is a double bypass. Bypassing three arteries is a triple bypass. Bypassing four arteries is a quadruple bypass.
The types of heart bypass surgery include:
On-pump surgery uses a heart-lung machine (cardiopulmonary bypass). This machine temporarily takes over the heart’s job of pumping oxygen-rich blood to the organs and tissues. This is the traditional type of heart bypass surgery. It allows your surgeon to operate on a heart that is not beating and has no blood traveling through it.
Beating heart or off-pump surgery does not use a heart-lung machine. Your surgeon operates on an actively beating heart. Your surgeon will slow your heart rate with medication or a device. This procedure can be used to bypass any of the coronary arteries.
Robot-assisted surgery allows your surgeon to use a special computer to control robotic arms that perform the surgery. The surgeon sees a three-dimensional view of the surgery on a monitor. This type of surgery is very precise and uses small, keyhole-size incisions.
The types of heart bypass grafts include:
Artery grafts most commonly use an internal mammary artery for the graft. This artery is inside your chest, close to your heart. Arteries are blood vessels that carry blood out to your body’s organs and tissues. Artery grafts are less likely than vein grafts to become blocked over time.
Vein grafts most commonly use a saphenous vein for the graft. It is a very long vein located in your leg, but it is not required for normal blood flow from your leg. Veins are blood vessels that carry blood from your tissues and organs back to your heart. Vein grafts are more likely than artery grafts to become blocked over time.
Other surgical procedures that may be performed
Your surgeon may also perform other procedures in addition to heart bypass surgery. These include:
Aortic aneurysm surgery to fix an aortic aneurysm. An aortic aneurysm is a weakened, dilated area in your aorta, the major blood vessel in your body.
Heart valve repair or replacement to treat or replace diseased valves. Heart valves keep blood flowing in one direction through the four chambers of your heart. They open to allow blood to flow forward to the body. They then close tightly so blood does not leak backwards into the heart.
Percutaneous coronary intervention or angioplasty to widen or open a blocked or narrowed artery.
Stenting to insert a mesh tube (stent) inside the coronary artery. The stent expands to keep the artery open after angioplasty. Stents remain in place to keep your coronary artery open.
Why is heart bypass surgery performed?
Your doctor may recommend heart bypass surgery to treat narrowed or blocked coronary arteries. Your surgeon may only consider heart bypass surgery for you if other treatment options with less risk of complications have failed. Ask your doctor about all of your treatment options and consider getting a second opinion before deciding on heart bypass surgery.
Your doctor may recommend heart bypass surgery to reduce your risk of heart attack when angioplasty and stenting are not an option. Angioplasty and stenting are less invasive procedures that can treat certain types of narrowed or blocked coronary arteries. Your doctor will base the decision to perform a heart bypass on:
Your symptoms, especially severe symptoms of coronary artery disease. This includes angina and shortness of breath. Angina is chest pain or discomfort.
The location of your blockage or blockages
The number of blockages you have
The severity of your blockage or blockages
Who performs heart bypass surgery?
A cardiac surgeon performs heart bypass surgery. Cardiac surgeons specialize in the surgical treatment of conditions of the heart and its blood vessels. A cardiac surgeon may also be known as a cardiothoracic surgeon.
How is heart bypass surgery performed?
Your heart bypass surgery will be performed in a hospital using one of the following approaches:
Minimally invasive coronary artery bypass (MIDCAB) is performed through a small (three to five inch) incision between your ribs. Minimally invasive surgery generally involves a faster recovery and less pain than open surgery. This is because it causes less trauma to tissues and organs. Your surgeon will make a small incision instead of a larger one used in open surgery. Surgical tools are threaded around muscles and tissues instead of cutting through or displacing them as in open surgery.
Port access coronary artery bypass surgery involves inserting special instruments and a thoracoscope through ports or very small incisions in your chest. A thoracoscope is a thin, lighted instrument with a small camera. The camera transmits pictures of the inside of your chest to a video screen viewed by the surgeon while performing surgery.
Open heart coronary artery bypass surgery involves making a large (six to 10 inch) incision in the chest and through the breastbone (sternum). An open surgery incision allows your surgeon to directly see and access the surgical area. Open surgery generally involves a longer recovery and more pain than minimally invasive surgery. Open surgery requires a larger incision and more cutting and displacement of muscle and other tissues than minimally invasive surgery. Despite this, open surgery may be a safer or more effective method for certain patients.
Your surgeon will advise you on which procedure is best for you and how long you need to stay in the hospital based on your diagnosis, age, medical history, general health, and possibly your personal preference. Learn about the different heart bypass surgery procedures and ask why your surgeon will use a particular type for you.
Types of anesthesia that may be used
Your surgeon will perform heart bypass surgery using general anesthesia. General anesthesia is a combination of intravenous (IV) medications and gases that put you in a deep sleep. You are unaware of the procedure and will not feel any pain.
You may also receive a peripheral nerve block infusion in addition to general anesthesia. A peripheral nerve block infusion is an injection or continuous drip of liquid anesthetic. The anesthetic flows through a tiny tube inserted near your surgical site to control pain during and after surgery.
What to expect the day of your heart bypass surgery
The day of your surgery, you can generally expect to:
Talk with a preoperative nurse. The nurse will perform an exam and ensure that all needed tests are in order. The nurse can also answer questions and will make sure you understand and sign the surgical consent form.
Remove all clothing and jewelry and dress in a hospital gown. It is a good idea to leave all jewelry and valuables at home or with a family member. Your care team will give you blankets for modesty and warmth.
Talk with the anesthesiologist or nurse anesthetist about your medical history and the type of anesthesia you will have.
A surgical team member will start an IV.
The anesthesiologist or nurse anesthetist will start your anesthesia.
A tube will be placed in your windpipe to protect and control breathing during general anesthesia. You will not feel or remember this or the surgery as they happen.
The surgical team will monitor your vital signs and other critical body functions. This occurs throughout surgery and your recovery until you are alert, breathing effectively, and vital signs are stable.
What are the risks and potential complications of heart bypass surgery?
As with all surgeries, heart bypass surgery involves risks and possible complications. Complications may become serious and life threatening in some cases. Complications can develop during surgery or recovery.
General risks of surgery
The general risks of surgery include:
Anesthesia reaction, such as an allergic reaction and problems with breathing
Bleeding, which can lead to shock
Blood clot, in particular a deep vein thrombosis that develops in the leg or pelvis. A blood clot can travel to your lungs causing a pulmonary embolism or to your brain causing a stroke.
Potential complications of heart bypass surgery
Complications of heart bypass surgery include:
Heart arrhythmias or problems with heart rhythm
Kidney or lung failure
Post-pericardiotomy syndrome, which is a low-grade fever and chest pain for up to six months following heart bypass surgery
Reducing your risk of complications
You can reduce the risk of some complications by following your treatment plan and:
Following activity, dietary and lifestyle restrictions and recommendations
Notifying your doctor right away of any concerns, such as bleeding, fever, increase in pain, or wound redness, swelling or drainage
Taking your medications exactly as directed
Telling all members of your care team if you have any allergies
How do I prepare for heart bypass surgery?
You are an important member of your own healthcare team. The steps you take before surgery can improve your comfort and outcome.
You can prepare for heart bypass surgery by:
Answering all questions about your medical history and medications. This includes prescriptions, over-the-counter drugs, herbal treatments, and vitamins. It is a good idea to carry a current list of your medical conditions, medications, and allergies at all times.
Getting preoperative testing as directed. Testing varies depending on your age, health, and specific procedure. Preoperative testing may include a chest X-ray, EKG (electrocardiogram), blood tests, and other tests as needed.
Losing excess weight before the surgery through a healthy diet and exercise plan
Not eating or drinking before surgery as directed. Your surgery may be cancelled if you eat or drink too close to the start of surgery because you can choke on stomach contents during anesthesia.
Stopping smoking as soon as possible. Even quitting for just a few days can be beneficial and help the healing process.
Taking or stopping medications exactly as directed. This may include not taking aspirin, ibuprofen (Advil, Motrin), and blood thinners.
Questions to ask your doctor
Facing surgery can be stressful. It is common for patients to forget some of their questions during a doctor’s office visit. You may also think of other questions after your appointment. Contact your doctor with concerns and questions before heart bypass surgery and between appointments.
It is also a good idea to bring a list of questions to your appointments. Questions can include:
Why do I need heart bypass surgery? Are there any other options for treating my condition?
What type of heart bypass surgery procedure will I need?
How long will the surgery take? When can I go home?
What restrictions will I have after the surgery? When can I return to work and other activities?
What kind of assistance will I need at home?
How should I take my medications?
How will you treat my pain?
Will I need a cardiac rehabilitation program after my surgery? What does that involve?
When should I follow up with you?
How should I contact you? Ask for numbers to call during and after regular hours.
What can I expect after heart bypass surgery?
Knowing what to expect can help make your road to recovery after heart bypass surgery as smooth as possible.
How long will it take to recover?
You will go to an intensive care unit (ICU) after surgery and initial recovery. ICUs provide 24-hour specialized monitoring and care.
It will take a few hours until the major effects of anesthesia wear off and you are alert. You will likely have a breathing tube in your mouth and tubes and wires attached to your body. These allow your team to monitor your vital signs, drain bodily fluids, take blood, and give medications and fluids.
You will not be able to talk if you have a breathing tube. The care team usually removes it within 24 hours. You may have a sore throat from the tube. This is usually temporary, but tell your care team if you are uncomfortable. You will also likely have drains in the heart and chest to drain fluid after surgery. These are removed in the first few days after surgery.
You may move to a hospital room outside the ICU as your recovery progresses. This room will have the equipment to monitor your heart rhythm and vital signs. Hospital stays after heart bypass surgery are typically five to seven days.
Recovery after surgery is a gradual process. Recovery time varies depending on the procedure, your general health, age, and other factors. Your surgeon will refer you to a cardiac rehabilitation program to help you recover. Full recovery takes a few weeks to a few months.
Will I feel pain?
Pain control is important for healing and a smooth recovery. There will be discomfort after your surgery. Your surgeon and care team will treat your pain so you are comfortable and can get the rest you need.
Tell your care team in the hospital or call your surgeon after you go home if your pain gets worse or changes in any way because it may be a sign of a complication.
When should I call my doctor?
It is important to keep your follow-up appointments after heart bypass surgery. Contact your surgeon for questions and concerns between appointments. Call your surgeon right away or seek immediate medical care if you have:
Breathing problems, such as shortness of breath, difficulty breathing, labored breathing, or wheezing
Change in alertness, such as passing out, unresponsiveness, or confusion
Chest pain, chest tightness, chest pressure, or palpitations
Fever. A low-grade fever (lower than 101 degrees Fahrenheit) is common for a couple of days after surgery and not necessarily a sign of a surgical infection. However, you should follow your doctor's specific instructions about when to call for a fever.
Inability to urinate or have a bowel movement
Leg pain, redness or swelling, especially in the calf, which may indicate a blood clot
Pain that is not controlled by your pain medication
Unexpected drainage, pus, redness or swelling of your incision
Weight gain of more than five pounds, which could indicate that you are retaining fluids, a potentially dangerous situation
How might heart bypass surgery affect my everyday life?
Heart bypass surgery may cure your condition or significantly reduce your symptoms so you can lead an active, normal life. For example, heart bypass surgery should relieve chest pain and reduce your risk of heart attack.
Heart bypass surgery will not prevent heart disease from coming back. You will need to make changes to your everyday life to prevent or delay recurrence of heart disease, such as:
Eating a heart-healthy diet
Getting regular exercise
Maintaining a healthy weight
Practicing stress management techniques
Treating other related conditions including high blood pressure, high cholesterol, and diabetes
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