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Definition

Surgery to restore blood flow to the heart muscle. This is done by moving blood vessels from other parts of the body into the heart to provide a route around obstructed coronary (heart) arteries.

	Coronary Artery Bypass Surgery
	© 2008 Nucleus Medical Art, Inc.

Parts of the Body Involved

Heart, chest, legs

Reasons for Procedure

Coronary artery bypass grafting (CABG) is performed to re-establish blood supply to the heart muscle. It is often recommended in cases of:

• Severe blockages in the main artery or obstructions in several blood vessels
• Persistent chest pain ( angina ) not improved with drug therapy

Risk Factors for Complications During the Procedure

• Pre-existing heart condition
• Lung disease, especially chronic obstructive pulmonary disease ( emphysema )
• Prior heart attack or bypass surgery
• Advanced age
• Surgical urgency
• Obesity
• Diabetes
• Smoking
• High blood pressure
• Thyroid disease

What to Expect

Prior to Procedure

Your doctor will likely do the following:

• Physical exam
• Chest x-ray
• Electrocardiogram (ECG, EKG) —a test that records the heart's activity by measuring electrical currents through the heart muscle
• Coronary angiogram —a test to determine the extent and location of blockages in blood vessels in the heart

• Do not take aspirin or other anti-inflammatory drugs for one week before surgery, unless told otherwise by your doctor.
• The night before, eat a light meal and do not eat or drink anything after midnight.
• Arrange for a ride to and from the hospital.
• Arrange for help at home after returning from the hospital.

During Procedure

• Anesthesia
• IV fluids
• Oxygen
• Catheter placed in your bladder to drain urine
• A heart-lung machine to maintain blood circulation and cool the blood and body temperature

Anesthesia

General

Description of the Procedure

The surgeon cuts through the skin and breastbone, opens the chest, and connects the heart-lung machine. This machine pulls blood from the heart, adds oxygen to it, and pumps it back into the bloodstream while the surgeon is working on the heart and/or lungs.

To harvest a blood vessel to graft into the heart, the surgeon may detach an artery from the chest wall, or make one or several incisions in the leg and remove a section of vein from the leg. Sometimes two surgeons work together, one on the chest and one on the leg to remove a vessel for grafting. The harvested vessels are connected (grafted) to the blocked arteries above and below existing obstructions. When the grafts are in place, the blood (and thus the body temperature) is rewarmed to normal temperature, and therapeutic electric shocks are used to start the heart beating again. The heart-lung machine is disconnected, the breastbone wired together, and the chest closed.

Certain medical centers are using a less invasive approach to coronary artery bypass grafting, called minimally invasive coronary artery surgery. The purpose of this surgery is the same, to bypass the clogged arteries, but the technique and indications are different. Patients who have only one or two clogged arteries may be candidates for this approach.

In this technique, a small incision is made in the chest, over the site of the clogged artery. The surgeon usually uses an artery from inside the chest wall to bypass the obstruction. The key difference in this technique is that the surgeon operates while the heart is beating, thus avoiding the use of the heart-lung machine. This type of surgery is promising, but the benefits and risks of the traditional procedure versus this new technique need to be weighed for each individual. Talk to your doctor about what is best for you.

After Procedure

You'll have close attention and monitoring in the intensive care unit. You'll be hooked up to various tubes and monitors, including:

• Heart monitor
• Pacing wires to help control heart rate
• Tubes connected to a machine that helps drain excess blood and air from the wound
• Breathing tube until you can breathe independently; then an oxygen mask
• Bladder catheter

How Long Will It Take?

4-5 hours

Will It Hurt?

Anesthesia prevents pain during surgery. You may experience pain during recovery, but will be given medications to relieve the discomfort.

Possible Complications

• Infection
• Pneumonia
• Phlebitis (blood clots in a vein), which can lead to heart attack or stroke
• High or low blood pressure
• Excessive bleeding
• Neurological deficits, stupor, coma , or decreased intellectual function
• Stroke
• Kidney dysfunction
• Irregular heart rate
• Depression
• Death

Average Hospital Stay

5-7 days

Postoperative Care

• Take medications as directed by your doctor. These may include:
  • Blood pressure medication
  • Digitalis—to help your heart pump more strongly
  • Anti-arrhythmics—to keep your heart's rhythms regular
  • Blood thinners—to prevent blood clots from forming
• To reduce the risk of fluid buildup in your lungs, breathe deeply and cough 10-20 times every hour.
• If a leg vein was removed, elevate your legs above your heart while sitting and do not cross legs.
• The day after surgery, try to walk with help.
• Dressings will be removed in a day or two; pacing wires and chest tubes will be removed after a few days.
• Internal stitches will dissolve; staples will be taken out 5-7 days after surgery.
• Small paper strips on incisions will peel off and can be removed one week after discharge.
• Once home, only take medications approved by your doctor, check your temperature twice daily, and weigh yourself every morning.
• Follow activity and cardiac rehabilitation program as recommended by your doctor to speed recovery and improve cardiovascular health.

Outcome

Bypass surgery restores blood flow through the heart, but does not cure heart disease; the grafted blood vessels can also become clogged. Therefore, you will be encouraged to make lifestyle changes to improve your cardiovascular health. These include exercising regularly, not smoking, and eating a heart healthy diet—one that is low in saturated fat, simple sugars, and salt, and high in fiber, fruits, and vegetables. Ask your doctor for a referral to a registered dietitian if you need help changing your dietary habits. Most patients can return to office-type work in 4-6 weeks.

According to a review of 23 studies, patients who received CABG had more angina relief and less need for another, similar procedure than those who received percutaneous coronary intervention (PCI). PCI involves techniques using balloon angioplasty or coronary stenting . *

Call Your Doctor If Any of the Following Occurs

• Signs of infection, including fever and chills
• Redness, swelling, increasing pain, excessive bleeding, or discharge at the incision sites
• Cough, shortness of breath, chest pain, or severe nausea or vomiting
• Pain, burning, urgency, frequency of urination, or persistent bleeding in the urine
• Gaining more than four pounds within one or two days
• Pain and/or swelling in your feet, calves, or legs, or sudden shortness of breath or chest pain

RESOURCES:

American Heart Association
http://www.americanheart.org

National Heart, Lung, and Blood Institute
http://www.nhlbi.nih.gov

CANADIAN RESOURCES:

Health Canada
http://www.hc-sc.gc.ca/index_e.html

Heart and Stroke Foundation of Canada
http://ww2.heartandstroke.ca/Page.asp?PageID=24

References:

American Heart Association website. Available at: http://www.americanheart.org .

National Heart, Lung, and Blood Institute website. Available at: http://www.nhlbi.nih.gov .

Updated Outcome section on 11/7/2007 according to the following study, as cited by DynaMed's Systematic Literature Surveillance : Bravata DM, Gienger AL, McDonald KM, et al. Systematic review: the comparative effectiveness of percutaneous coronary interventions and coronary artery bypass graft surgery. Ann Intern Med. 2007 Nov 20. [Epub ahead of print]

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