What is heart bypass surgery?
Coronary Artery Bypass Graft (CABG) is a type of surgery that aims to increase blood flow to the heart's arteries. Cardiac surgeons indicate this procedure to treat people who have severe coronary heart disease, for which it is not enough just to use drugs and or heart catheterization with balloons or stents.
Coronary heart disease is caused by a buildup of plaque (cholesterol) in the heart's blood vessels (commonly called the coronary arteries). This cholesterol plaque buildup can also cause hardening of the arteries (arteriosklerotic). These cholesterol plaques if left unchecked will result in blockages in your coronary arteries. Under normal circumstances, the coronary arteries carry blood and oxygen to your heart. This accumulation and blockage results in reduced blood flow to the heart, furthermore it can even result in the cessation of blood flow to the heart, a condition that can cause ischemia and infarction (death) in certain areas of the heart.
The doctor may first give you medicines. Then also try exercise and diet to make a change, or even with a heart catheter angioplasty (balloon) or with a stent. Your doctor may recommend this heart bypass procedure if you have one or more blockages of the coronary arteries, if they cannot be treated with conservative management as above.
This bypass operation is performed to create a new pathway for blood to flow to the heart. The surgeon will use a chest wall vein and take a piece of the good vein from your leg or the artery in your wrist. Then the surgeon connects it to the coronary artery, just below the area of the narrowed or blocked coronary artery. This will allow the blood to flow again through the new pathway to the heart. It's not uncommon for people to need more than one bypass.
Reasons for having a heart bypass procedure
Coronary artery bypass surgery is performed to treat blockages or narrowing of one or more coronary arteries, which aims to improve blood flow to the heart muscle.
Symptoms of coronary heart disease include:
- Chest pain (can be stabbing, pressing, or even non-specific)
- Fatigue
- pounding
- Heart rhythm abnormalities
- Out of breath
Sometimes patients have no complaints or symptoms in the early stages of coronary heart disease, but the disease will continue to progress until the artery blockage is large enough to cause symptoms and problems. If the blood supply to the heart muscle continues to decrease as a result of increasing coronary artery obstruction, myocardial infarction or heart attack can occur. If blood flow cannot be restored to a certain area of the affected heart muscle, then a part of the heart tissue dies.
The goals of a heart bypass/CABG procedure include:
- Improve quality of life and reduce angina and other symptoms of coronary heart disease
- Allows you to continue a more active lifestyle
- Increase your heart's pumping if it has been reduced by a heart attack
- Reducing the risk of heart attack (in some patients, especially those with high risks such as diabetes mellitus)
- Improve patient quality of life
CABG using the internal mammary artery and saphenous vein
Before Operation
Always tell your doctor or nurse what medicines you are taking, even traditional medicines or herbs. This aims to reduce the risk (especially bleeding) during surgery.
During the days before your surgery:
- 2 weeks before surgery you may be asked to stop taking medications that act as blood thinners. Because it will cause increased bleeding during and after surgery. If you are taking blood thinners, talk to your surgeon about when to stop taking them.
- Ask your doctor what medications you still need to take on the day of surgery.
- If you smoke, try to quit.
- Call your doctor if you have a cold, flu, fever, herpes, or any other illness.
- Prepare your home so you can move around easily when you return from the hospital.
The day before your surgery:
- Usually several examinations are still needed, if the previous examination is still incomplete. Then you will receive a complete explanation from the anesthesiologist and surgeon regarding the operation, which will be followed by informed consent from both specialist doctors (anesthesiologist and cardiac surgeon).
- Take a good shower with soap and disinfectant shampoo.
- You may be asked to shave the area to be operated on and wash your entire body below your neck with a special soap.
On the day of operation:
- You will usually be asked not to drink or eat anything after midnight the night before your surgery. Rinse your mouth with water if it feels dry, but be careful not to swallow.
- Take the medicine your doctor gave you with a small sip of water.
Heart bypass surgery procedure
Coronary artery bypass with the aid of a heart-pulmonary machine
- The heart surgeon will make an incision in the middle of the chest, approximately 20 cm. For the purpose of sewing the new blood vessels to the coronary arteries, the heart will be stopped temporarily. The heart will be connected to a heart-lung machine with sterile tubes, so that the function of the heart as a blood pump will be taken over by the machine during the operation.
- After the blood is diverted to a bypass machine to pump, the heart will stop along with an injection of cold cardioplegic fluid (a fluid that protects the heart against infarction).
- When the heart has been stopped, the doctor will perform a bypass procedure by sewing one end of the vein through a small hole made in the coronary artery just below the blockage, and the other end is sutured to the aorta. If the internal mammary artery in your chest is used as a bypass graft, then the lower end of the artery will be cut from inside the chest and sutured through the small hole made in the coronary artery under the blockage.
- You may get more than one bypass graft, depending on how many blockages you have and where they are. After all the suturing and connecting of the blood vessels has been completed, the doctor will check again to make sure the bypass graft that has been done is optimal.
- After the bypass procedure is complete, the blood circulating through the heart-lung machine will be returned to the heart, and the heart will work normally again.
- Because the heart's function is not optimal immediately after bypass, the surgeon will install a temporary pacemaker, which will be removed a few days after surgery. In addition, a tube will also be installed to remove residual blood from the chest cavity, which will also be released within two or three days after the operation.
Coronary artery bypass without the aid of a heart-pulmonary machine
- After the chest has been opened, the area around the artery to be bypassed is stabilized with special instruments.
- The heart will continue to function by pumping blood throughout the body.
- The heart-lung machine will be on stand-by while the bypass procedure is being performed.
- The doctor will perform a bypass graft procedure by sewing one end of the venous section through a small hole made in the aorta, and the other end through a small hole made in the coronary or internal mammary arteries just below the blockage.
- You may have more than one bypass graft done, depending on how much blockage you have and where the blockage is.
- Before the chest is closed, the doctor will re-examine the bypass connection to ensure that the bypass is working optimally.
Internal mammary artery
The blood vessel most commonly used for bypass is the left internal mammary artery. This artery is separated from the chest wall and is usually connected to the left coronary artery and/or one of its main branches outside the occlusion. The main advantage of using the internal mammary artery is that it has a longer bypass life (less likely to experience narrowing) than the saphenous vein. From the results of research, ten years after CABG surgery, only 66% of the bypass uses a vein that is still patent (open) compared to 90% of the bypass using the internal mammary artery. However, the internal mammary artery is very limited in length and can only be used to bypass the nearest coronary vessel. Using the internal mammary artery can prolong CABG surgery because it requires additional time to separate it from the chest wall. Therefore, the internal mammary artery cannot be used for emergency CABG/bypass surgery when time is critical to restore coronary artery blood flow to prevent immediate cardiac infarction.
Saphenous vein or radial artery
Alternatives or frequently used also for heart bypass are the saphenous vein (from the leg) and the radial artery (blood vessel in the arm). The procedure for taking the two blood vessels can use an open (open) or endoscopic (keyhole surgery) procedure with the help of a camera and small incisions on the legs or arms.
The conventional (open) method of taking the saphenous vein or radial artery is by making a long surgical incision to the inner thigh and/or calf for taking the vein, or also an incision is made on the inner arm.
After Procedure
After surgery, you will spend 3 to 7 days in the hospital. You will spend the first day after surgery in the intensive care unit (ICU). Two to three tubes will be in your chest to drain fluid and residual blood from around your heart, which will be removed 2-3 days after surgery. You will also get a catheter to drain urine in addition to a small tube in the neck and wrist area for infusion of fluids and medicines. The nurse will constantly monitor you while you are in the ICU. You will be assisted with various activities and can start a cardiac rehabilitation program within a few days of surgery.
It will take 4 to 6 weeks for your condition to start feeling better after surgery. Your nurse and doctor will tell you how to care for yourself at home after surgery.
Prognosis
Recovery from heart bypass surgery takes time. You may not see the full benefit of your surgery for 3 to 6 months after surgery. In most people who have had heart bypass surgery, the bypass will stay open and work well for years.
This surgery does not prevent coronary artery blockages from coming back. But you can do many things to prevent it or slow down the process of re-blockage, such as:
- Do not smoke
- Consuming healthy food (cardiac diet)
- Get regular exercise
- Control and treat high blood pressure
- Control blood sugar (if you have diabetes) and cholesterol
You may be more likely to have problems with your blood vessels if you have kidney disease or are a heavy smoker.
At home
After you return home, it is very important to keep the surgical wound clean and dry. The doctor will give specific bathing instructions. The stitches will be removed (depending on the type of thread used during the operation) during your return visit. Discuss again with your doctor about any activities that must be limited and allowed and how long you should do this.
Tell your doctor if any of the following occur:
- Fever or chills
- Redness, swelling, bleeding or discharge from the surgical wound
- Increased pain around the surgical site
Article written by dr. Achmad Faisal, Sp.BTKV, Subsp. T(K) (Specialist in Thoracic, Cardiac and Vascular Surgery, Consultant Thoracic Surgery at EMC Alam Sutera Hospital).