Patient Care — Adult cardiac, endovascular, and thoracic aortic surgery
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Bypass surgery - Surgery done to by-pass clogged arteries supplying the heart. Other names - CABG; Coronary artery bypass graft.
Coronary arteries are the small blood vessels that supply the heart muscle with oxygen and nutrients. Fats and cholesterol can accumulate inside these small arteries, and the arteries can gradually become clogged. (This buildup of fat and cholesterol plaque is called atherosclerosis.)
When one or more of the coronary arteries becomes partially or totally blocked, the heart does not get an adequate blood supply. This is called ischemic heart disease or coronary artery disease (CAD). It can cause heart pain (angina).
Sometimes it does not cause pain until the blood supply to the heart becomes critically low, and the muscle begins to die. The first symptom of CAD in this case may be a potentially deadly heart attack (myocardial infarction). Symptomless CAD is especially common in diabetics.
Heart bypass surgery creates a detour or "bypass" around the blocked part of a coronary artery to restore the blood supply to the heart muscle. The surgery is commonly called Coronary Artery Bypass Graft, or CABG (pronounced "cabbage").
After the patient is anesthetized and made completely free from pain, the heart surgeon makes an incision in the middle of the chest and separates the breastbone.
Through this incision, the surgeon can see the heart and aorta (the main blood vessel leading from the heart to the rest of the body). After surgery, the breastbone will be rejoined with wire and the incision will be sewn closed.
If a vein from the leg (the saphenous vein) is to be used for the bypass, an incision is made in the leg and the vein removed. The vein is located on the inside of the leg running from the ankle to the groin.
It normally does only about 10% of the work of circulating blood from the leg back to the heart. Therefore, it can be taken out without harming the patient or adversely affecting the leg. It is common for the leg from which the vein is taken to swell slightly during recovery from the surgery, but this is only temporary and treated with elevation of the leg.
The internal mammary artery (IMA) can also be used as the graft. This has the advantage of staying open for many more years than the vein grafts, but there are some situations in which it cannot be used.
The left IMA or LIMA is an artery that runs next to the sternum on the inside of the chest wall. It can be disconnected from the chest wall without imparing the blood supply to the chest. It is commonly connected to the artery on the heart that supplies most of the muscle, the left anterior descending artery or LAD.
Other arteries are also now being used in bypass surgery. The most common other artery used is the radial artery. This is one of the two arteries that supply the hand with blood. It can usually be removed from the arm without any impairment of blood supply to the hand.
The entire surgery can take four to six hours. After the surgery, the patient is taken to the Intensive Care Unit. For a few days after the surgery, the patient is connected to monitors and tubes. Other techniques to do this surgery are used more and more frequently. One popular method is to avoid the use of the heart-lung machine. This is called off-pump coronary artery bypass or OPCAB.
When considering the risks of CABG, it is important to remember that bypass surgery has been performed for more than 30 years. Cardiovascular surgeons have received extensive training in bypass techniques.
It is the most frequently performed major surgery in the United States, with over a half of a million done each year. As with any surgery, the health of the patient prior to surgery is a major consideration in determining risks.
CABG will improve blood flow to the heart but NOT prevent the eventual recurrence of coronary blockage. Lifestyle changes are necessary -- such as not smoking, improved diet, regular exercise, and treating high blood pressure and high cholesterol.
Convalescence: After the operation, the patient will spend 5-7 days in the hospital, with the first 2 hours in an intensive-care unit (ICU). In the ICU, heart function is monitored continuously.
Patients may require the temporary assistance of a breathing tube for a few hours after surgery. Two to three tubes in the chest drain fluid from around the heart and are usually removed one to three days after surgery.
A urinary catheter in the bladder drains urine until the patient is able to void on his own. Intravenous lines (IV) provide fluids and medications. Nurses watch the monitors and check vital signs (pulse, temperature, breathing) constantly.
When constant monitoring is no longer needed, usually within 12-24 hours, the patient is moved to a regular or a transitional care unit. Activity is gradually resumed and the patient may begin a cardiac rehabilitation program within a few days. The incision in the chest does not bother most people after the first 48-72 hours.
After surgery, it takes 4-6 weeks to start feeling better. Normal discomforts during recovery include:
- poor appetite -- it will take several weeks for it to return.
- leg swellilng if the graft was taken from the leg. Elevating the leg and wearing elastic TED hose for several weeks helps reduce swelling.
- difficulty sleeping at night -- this will improve.
- constipation.
- mood swings and feel depressed -- this will get better.
- difficulty with short-term memory or feel confused -- this also improves.
The full benefits from the operation may not be determined until 3-6 months after surgery. All activities that do not cause fatigue are permitted, and the schedule for resuming normal activities is determined with the physician.
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