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Open Heart Surgery (CABG)

CORONARY ARTERY BYPASS GRAFTING (CABG)

WHAT IS A CORONARY ARTERY BYPASS GRAFTING (CABG)?

Coronary artery bypass grafting is open heart surgery which creates a new path for blood to flow around a blocked artery ( caused by Coronary artery disease). The path is usually a tube (artery or vein) which is removed from elsewhere in the body and sewn to an area beyond the area of narrowing or blockage. These tubes allow blood to flow around the previous blockage and supply blood to the area beyond this blockage. This procedure is usually done with the aid of the heart lung machine while the heart is stopped; however,it can also be performed on the beating heart. Each area of narrowing/blockage is remedied by an individual bypass so that all the blockages are relieved with these new paths. The number of bypasses correlates with the number of arteries which are blocked. Under most circumstances the blockages themselves are not removed.

KEY POINTS
1. Coronary artery bypass grafting is open heart surgery which creates a new path for blood flow around a blocked artery
2. Under most circumstances the blockages themselves are not removed.
3. This procedure is usually done with the aid of the heart lung machine, however, can also be performed on the beating heart.

SYMPTOMS, RISK FACTORS, DIAGNOSIS

Symptoms, risk factors, and diagnosis of coronary artery disease are identical as for myocardial infarction.

What are the Indications for a CABG

Indications for heart bypass surgery include significant blockage of the left main heart artery (left main coronary stenosis), and significant blockage in three of the main arteries in the heart (three vessel disease). Other induications include significant blockage of one artery on the front and left side of the heart (that is, the left anterior descending artery), failed balloon angioplasty, and while performing other procedures which require open heart surgery.

What happens during surgery

Usually bypass surgery takes 3 to 5 hours, but can be longer in complex or difficult cases. A standard incision is made in the middle of the chest and the breast bone (or sternum) is completely cut down the center portion. Coronary artery bypass grafting creates a new path for blood to flow around a blocked artery . The path is usually a tube (artery or vein) which is removed from elsewhere in the body and sewn to an area beyond the area of narrowing or blockage. These tubes allow blood to flow around the previous blockage and supply blood to the area beyond this blockage. This procedure is usually done with the aid of the heart lung machine while the heart is stopped; however, can also be performed on the beating heart. Each area of narrowing/blockage is remedied by an individual bypass so that all the blockages are relieved with these new paths. The number of bypasses correlates with the number of arteries which are blocked. Under most circumstances the blockages themselves are not removed.

After completion of open heart surgery the patient is admitted to the intensive care unit. The breathing tube (ventilator) is usually removed in 6 to 12 hours after bypass surgery, but occasionally in the operating room immediately after completion of the surgery. Intravenous medications are slowly withdrawn during the initial days after surgery and oral medications initiated. Tubes which were inserted at surgery are also removed in the same time frame. After the patient stabilizes, transfer to a monitored room out of the intensive care unit occurs. This can take place as early as one day after the operation or can occur much later with complex cases. Activity is increased as the above measures are conducted and the patient’s oxygen is withdrawn as the need for it is eliminated. The total hospital stay for bypass surgery is about one week and the average day of discharge is 4 to 5 days after the surgery.
What should I expect after surgery?
At home, recuperation includes light activity without heavy lifting or straining. Usually the patient visits the heart surgeons’ office several weeks after discharge. Cardiac rehabilitation is a formal program which includes progressive exercises to aid in recovery to at or above the patient’s previous functional capacity. Full recovery usually takes 2 to 3 months.

KEY POINTS

1. Usually coronary artery bypass surgery (CABG) takes 3 to 5 hours, but can be longer in complex or difficult cases.
2. After completion of open heart surgery the patient is admitted to the intensive care unit.
3. After the patient stabilizes for one to several days they are transferred to a monitored room out of the intensive care unit occurs.
4. The total hospital stay for bypass surgery is about one week and the average day of discharge is 4 to 5 days after the surgery.
5. Full recovery from coronary artery bypass surgery usually takes 2 to 3 months, but can be prolonged with various complications.

COMPLICATIONS

Just as there may be benefits to the procedure(s) proposed medical and surgical procedures also involve risks. These risks include allergic reaction, bleeding, blood clots, infections, adverse side effects of drugs, heart attack and stroke, and even loss of bodily function or life, as well as risks of transfusion reactions and the transmission of infectious disease, including hepatitis and Acquired Immune Deficiency Syndrome (AIDS), from the administration of blood and/or blood components.

There are particular risks associated with the procedure(s)
Usually coronary artery bypass grafting is successful; however, risks exist which may increase the incidence of complications after the operation. These can occur within the first several hours or months after bypass grafting. Risk factors which increase the risk of complications include the severity of coronary artery disease, age (greater than 65 year old), female sex due to smaller, technically more difficult bypasses, previous bypass surgery, preoperative heart attack, associated heart valve disease, disease in the blood vessels outside of the heart, an emergency procedure, obesity, poor heart function, low blood count, and the presence of other medical illnesses including diabetes, kidney failure, and emphysema.

During the operation or within the first several hours bleeding requiring blood transfusion or reoperation may occur. The heart’s function may also diminish within the first several hours and require additional medications or a device called an intraaortic balloon pump to aid the heart’s performance. A balloon pump is placed through the groin and pumps additional blood into the heart increasing the amount of oxygen rich blood supplied to the heart to increase its effectiveness. It also pushes blood away from the heart in order to decrease the work the heart has to do on the next heart beat. Within the first weeks or month after bypass surgery lung failure may also occur requiring the breathing tube (ventilator) for extended periods of time. This may lead to an additional procedure in which the tube is switched by placing an incision in the neck called a tracheotomy. This is done primarily to ease withdrawal of the ventilator but to also preserve the voice box. Kidney failure may also occur to varying degrees. Occasionally it is severe and requires temporary or permanent dialysis.

A stroke may also occur with symptoms which include difficulty or inability to speak or understand speech, difficultly or inability to move an arm or a leg, loss of vision in one or both eyes, loss of balance or coordination, numbness in the face, arm, or leg especially on one side of the body. Other complications include infection, heart attack, circulatory problems including poor circulation to the intestines, liver, legs, and inflammation of the pancreas. A syndrome can also occur within the first 4 days to two weeks which causes a patient to be constantly tired with achy painful joints called postpericardiotomy syndrome. This is typically treated with ibuprofen with relatively rapid relief of these symptoms. Late complications include occlusion of the bypasses, memory deficits, and the breast bone (sternum) not healing.

Before you agree to any operative procedure it is important to remember that each patient is different and that the outcome of any surgical procedure can never be guaranteed. You should understand that there may be complications that have not been mentioned and that it is not possible to anticipate all complications or to answer each and every question. Again, You should be aware that in the practice of medicine unforeseen and unexpected risks or complications not previously discussed may occur. You should also understand that during the course of the proposed procedure(s) unforeseen conditions may be revealed requiring the performance of additional procedures, and such procedures may necessarily be performed.

Keep in mind that there is no substitute for an open and honest discussion with your own surgeon/physician (depending on if is a surgical procedure) regarding this procedure.

You should also be given any available treatment alternatives to this procedure by your doctor, some of which may include medication. Be sure to discuss any questions or concerns with your doctor.

PATIENT TIPS
1. Coronary artery bypass surgery is common and most often successful
2. Coronary artery bypass surgery is the treatment of blockages in the heart which can return if a life style change is not undertaken including smoking cessation, dietary modifications, regular exercise, and monitoring and treatment of other medical conditions.
3. Usually coronary artery bypass surgery (CABG) takes 3 to 5 hours, but can be longer in complex or difficult cases.
4. After completion of open heart surgery the patient is admitted to the intensive care unit.
5. After the patient stabilizes for one to several days,the patient is are transferred to a monitored room out of the intensive care unit occurs.
6. The total hospital stay for bypass surgery is about one week and the average day of discharge is 4 to 5 days after the surgery.
7. Full recovery from coronary artery bypass surgery usually takes 2 to 3 months, but can be prolonged with various complications.
8. Complications occur sporadically but include bleeding, infection, heart attack, stroke, kidney failure, lung failure, bypass closure, and mortality.