Coronary Bypass Surgery
Why Bypass Surgery?
Generally, bypass surgery is done either to reduce syptoms of coronary heart disease, such as angina or to help prevent a heart attack.
Coronary Heart Disease
The inside walls of arteries are normally smooth and flexible, allowing blood to flow through them easily. Over the years, the inside of an artery's wall may become plugged with fatty deposits.
As these fatty deposits, known as plaque, continue to build up, they narrow the inside of the arteries and can reduce the flow of blood. These deposits may sufficiently reduce blood flow in the coronary arteries to cause angina or heart attack.
Angina is a pain or discomfort in the chest, arm, or jaw that occurs when an area of the heart muscle does not receive enough oxygen. In most cases, the inadequate supply of oxygen is caused by narrowed or blocked coronary arteries. Angina typically occurs with exertion or stress, when the heart works harder and needs more oxygen.
Patients with angina are at risk of developing a heart attack. A heart attack occurs when a coronary artery is completely blocked by a blood clot. The area of the heart muscle fed by that artery dies and then turns into scar tissue as it heals. A scarred heart may not pump as efficiently as a normal heart.
How is the Diagnosis Made?
If your doctor suspects you have coronary disease, he or she will recommend diagnostic tests such as an exercise test, a heart scan and cardiac cathetertization.
Cardiac catheterization is a procedure in which a catheter (a long, flexible tube) is inserted into a blood vessel and slowly advanced to the heart.
Cardiac catheterization allows doctors to assess the heart's pumping action and take pictures of the coronary arteries. In patients with coronary heart disease, the pictures indicate where the blockages are and how severe they are. Such information is important in helping doctors select the best treatment.
What are the Treatment Options?
Several options are available for treating patients with coronary heart disease, including medications, coronary angioplasty and bypass surgery.
Medications can help reduce symptoms of angina either by improving the supply of oxygen to the heart muscle and/or reducing the heart's need for oxygen. However, drugs do not eliminate existing blockages in the arteries.
Coronary angioplasty is a technique used to widen the passageway in narrowed arteries without surgery. It relieves symptoms of angina by improving blood flow to the heart muscle. During the procedure, a special catheter with a small balloon at its tip is guided into the diseased artery. When the catheter reaches the narrowed or blocked area, the balloon is inflated. This stretches the artery and flattens the plaque against the artery's wall.
A small mechanical device, called a stent, is often placed in the artery at the time of angioplasty to help keep the vessel open. Early regrowth of plaque (known as restenosis) is a major disadvantage of angioplasty. About a third of patients experience regrowth of plaque within six months after initially successful angioplasty.
In about half of patients with coronary heart disease, angioplasty may not be an option. This is the case, for example, when there are multiple blockages in several coronary arteries, or when the blockage is at a point where an artery divides.
During bypass surgery, surgeons use a blood vessel from the leg or chest to make a graft. One end of the graft is attached to the aorta, and the other end is sewn to the diseased coronary artery, beyond the blockage. With the graft in place, blood goes around the narrowed or blocked section of the artery and flows freely to the heart muscle.
When is Bypass Surgery Needed?
If bypass surgery is a likely option, your doctor will discuss the reasons it is needed. In general, the following conditions indicate that bypass surgery may be the best treatment:
- A blockage in the left main artery (the vessel that supplies the most blood to the heart muscle).
- Severe blockages in two or three major coronary arteries, especially when the heart is weakened and doesn't pump as well as it should.
- Significant symptoms of angina that do not respond to medications and/or cannot be treated with coronary angioplasty.
What are the Possible Risks?
Bypass surgery is major surgery and, in spite of all reasonable precautions, problems can occur. Possible complications include:
- Lung and breathing problems
- Wound infection
- Nerve injury
- Abnormal heart rhythms
- Kidney failure
- Heart attack, stroke or death
Although most bypass patients do not experience major problems, you should know the risks. To learn about your particular risk, talk with your doctor.
Factors that may increase the risk during surgery include: a weakened or damaged heart, advanced age, marked obesity, heavy smoking and serious lung or kidney disease. The risk is also increased during emergency bypass surgery.
Despite an initially successful operation, some people will eventually develop symptoms again. Most often, this is caused by the progression of disease in the coronary arteries. Less often, new fatty deposits build up inside the bypass graft(s).
What are the Potential Benefits?
The two main goals of bypass surgery are to relieve symptoms of angina and to prolong life. The effect of surgery on relieving symptoms is often significant. About 90 percent of bypass patients either become free of angina symptoms or have fewer symptoms. Many patients remain totally free of symptoms for years.
The effect of surgery on prolonging life, on the other hand, is not as clear-cut. Most experts agree that surgery usually prolongs life in people who have disease of the left main artery or severe blockages in all three major coronary arteries.
Preparing for Surgery
Unless you are already hospitalized, you will probably be admitted the day before surgery. Or, you may be asked to check in early on the morning of surgery.
At the Hospital
Several lab tests will be performed, including blood and urine tests, electrocardiograms (ECGs) that record your heart's electrical activity and chest x-rays.
You will meet with the members of the cardiac care team both before and after your surgery. The team includes a cardiologist (heart specialist), a heart surgeon, assistant surgeons, cardiac nurses, physical therapists and other medical personnel.
A patient educator or a nurse may talk with you and your family about what you can expect before and after the operation.
Before Your Admission
You may need to stop taking aspirin or some other medicines, since they can cause excessive bleeding during surgery. Ask your doctor.
If you smoke, stop now. This will improve blood flow and help your breathing.
You may want to talk to your doctor about possibly setting aside some of your own blood before surgery. Then, if you need a transfusion, your own blood will be available.
One of the doctors involved in your surgery will review your medical history and examine you. (You may be seen by the doctor at the office several days before the operation.)
The doctor will explain the operation, its purpose, potential benefits and possible risks. This is a good time to ask questions and share any feelings or concerns you may have about the procedure. You will then be asked to sign a consent form.
The anesthesiologist, the doctor who will keep you asleep and free of pain during surgery, will also talk with you before the procedure.
On the evening prior to surgery, you will be asked to shower and wash your body with an antiseptic soap. Your chest, groins and legs will be shaved. Cleansing and shaving helps to avoid infections.
You will be asked not to eat or drink anything after midnight the night before surgery. This is to prevent vomiting during the operation. You will also be given a sedative on the morning of surgery and perhaps the night before, to help you relax.
On the morning of surgery, you will be taken on a movable bed to the operating room area.
The Bypass Operation
The surgery team for bypass surgery usually includes the heart surgeon, assistant surgeons, a perfusion technologist (who operates the heart-lung machine) and specially trained nurses. The anesthesiologist constantly monitors your anesthesia to help you sleep safely and without pain.
Once you have been given anesthetic medications, you will be deeply asleep and unaware of the activity around you. A number of tubes and lines will be inserted to help you breathe, to drain fluids and to monitor your vital functions.
Preparing the Grafts
The surgery begins with removal of the blood vessels that will form the bypass grafts. These may be sections of a vein in the leg, an artery from inside the chest, or both.
One way to make grafts is to use the saphenous vein in the leg. One or more incisions are made along the inside of the thigh or calf and sections of the vein are removed. Because the vein is not crucial for blood flow in the leg, it can be removed safely.
Another way to make grafts is to use the internal mammary artery, one of the two arteries that supply blood to the inside of the chest. The artery's upper end is left untouched, since it's already attached to a branch of the aorta. The lower end is separated from the chest wall and used as a graft.
Opening the Chest
The surgeon makes an incision down the middle of the chest, and the breastbone is divided in two. The breastbones two halves are separated and held open during the operation. The surgeon then exposes the beating heart.
Circulating the Blood
Before the delicate grafting can begin, your heart's action must be stopped. During that time, the blood is passed through a heart-lung machine ("pump"). This machine takes over the work of your heart and lungs during surgery, supplying your blood with oxygen and pumping it back through your body.
Attaching the Grafts
If the saphenous vein is used to make a graft, one end of the vessel is sewn, with very fine sutures, to an opening in the coronary artery beyond the blockage. The other end is sewn onto the aorta.
If the internal mammary artery is used, one end is already attached to a branch of the aorta. The other end is sewn to an opening in the coronary artery below the blockage.
With the graft (either vein or artery) in place, blood can now flow freely from the aorta into the coronary artery and to the heart muscle.
A graft is attached to each coronary artery that needs to be bypassed. Therefore, you may have "single," "double," "triple," or "quadruple" bypass, depending on the number of arteries or major branches that require a graft.
Completing the Surgery
Once the grafts are securely in place, your heart can start pumping on its own again and the heart-lung machine is removed.
As the surgeons complete the operation, they bring the breastbone back together with several strands of stainless steel wire. These wires will remain in place permanently, so the bone will not shift when you move about during the healing period.
The skin is then sutured and covered with a sterile dressing. Stitching is done with either surgical staples or suture material. Staples and sutures will usually be removed before you go home.
Still deeply asleep, you'll be transferred from the operating table to a movable bed, then transported to the intensive care unit (SICU). Bypass surgery generally takes from three to six hours, depending on the number of arteries being bypassed and the complexity of the operation.
After Your Surgery
After surgery, you'll be taken to the intensive care unit (SICU), where your condition will be constantly monitored during the early stages of recovery.
Waking Up in the SICU
When you wake up after surgery, you may feel sore, cold and perhaps disoriented. These sensations are common and they won't last long.
You will notice a variety of tubes and devices that were put in place while you were asleep. These devices help doctors and nurses observe you closely and care for you during recovery.
A heart monitor continuously records your heart's electrical activity. If an abnormal heart rhythm develops, the device sounds an alarm.
A breathing tube is placed in your throat while you are asleep. The tube is connected to a ventilator that helps you breathe during and after surgery.
Chest tubes are inserted during surgery and are used to drain blood and other fluids that tend to build up around the heart. These tubes come through the chest wall and are attached to a drainage device.
Other tubes and lines may be inserted during or after the operation. These include: intravenous lines to give you fluids and drugs; an arterial catheter to monitor blood pressure and provide blood samples for lab studies; and a urinary catheter to drain the urine from your bladder.
What to Expect in the ICU
Because the breathing tube passes through your voice box, you will not be able to talk while it is in place. You will be able to communicate by making gestures or writing notes. The breathing tube is usually taken out within a day after the operation.
You will be encouraged to start moving as soon as you can, to prevent blood clots in your leg veins. You will be asked to wiggle your toes, move your ankles and bend your knees, all of which help blood flow.
As soon as the breathing tube is removed, you will be helped to sit up in bed. Later, you will be encouraged to dangle your legs over the side of the bed and then to sit in a chair next to the bed.
You will be shown how to do breathing and coughing exercise. The purpose of these exercises is to clear and expand your lungs in order to help prevent lung problems, such as pneumonia.
It is common to have some pain after the operation, especially at the incisions. You will receive medications to relieve pain, whatever its cause.
As you continue your progress, the various tubes and lines that were inserted during the operation will gradually be removed.
Moving Out of the ICU
When you no longer need constant care, usually within two days after surgery, you will be moved to a regular hospital room. You will still remain under continued observation for abnormal heart rhythms, fever and infection of the incision sites.
Gradually, you will be allowed to walk in your room, then in the hallway. As your recovery continues, you will be less dependent on others and able to do more for yourself.
High Point Regional Health has a cardiac rehabilitation program. The physical therapist (or your nurse) will guide you through daily exercises, such as walking around the unit, riding a stationary bicycle and climbing stairs. You may also receive an exercise plan to follow after you go home.
Most bypass patients stay in the hospital for a total of four to seven days after the operation; how long you stay will depend on your progress.
Before you leave the hospital, your doctor or nurse will talk with you about medications, the type of foods you can have and the activities you can safely do at home. Feel free to ask questions.
On the day of discharge, plan your activities so that you get plenty of rest. If you need it, ask for pain medication before leaving. Have someone drive you home and be sure to use your car seat belt.
Although the rate of recovery after surgery may vary, it takes about six to eight weeks for most people to get back to normal. During that time, it is important to follow your doctor's instructions.
You will be asked to see your doctor within a week or two after you leave the hospital. Follow-up visits with your doctor help ensure that you are recovering safely after surgery. To monitor your progress, you may have a number of diagnostic tests, such as chest x-rays, blood tests, electrocardiograms or a treadmill test.
Your doctor may prescribe a variety of medications to help control your blood pressure, regulate your heart rhythm, lower your cholesterol, prevent blood clots and/or relieve pain.
- Be sure you understand what each medication is for. If you do not know, ask your doctor.
- Know when and how often you should take each medicine. Try taking it at the same time or times each day.
- If you think you are having a side effect, call your doctor. Do not just stop treatment!
- Even if you start to feel better, do not stop taking your medications or change the dosage unless your doctor advises you to.
When to Call Your Doctor
You should call your doctor if you notice any of these warning signs:
- Increased redness, swelling, or pain around your incision sites or yellowish drainage from the incisions.
- Significant fever (over 100ºF) or fever that persists for more than three days (even if less than 100ºF). Shaking chills.
- Significant shortness of breath while resting or during minimal activity.
- Excessive swelling of your feet, ankles and legs. Weight gain of two or three pounds in one day or five pounds in one week.
- Excessive or persistent fatigue.
- Pain or discomfort in the chest, arm, or jaw that becomes more frequent, more severe or that occurs with minimal activity.
- Chest pain that is worse with coughing or deep breathing. Persistent cough.
- Palpitations (pounding in the chest). Dizzy or fainting spells. A heart rhythm that is too fast, too slow or irregular.
- Any symptoms that you are experiencing and are concerned about.
In general, the breastbone heals in about four to six weeks, while incisions in the thigh or calf take about two to three weeks. During that period, the incisions may feel sore, numb or itchy.
Some patients develop inflammation, marked by redness, swelling and pain at the incision site. This usually goes away within a few days.
Occasionally, an incision becomes infected, resulting in small amounts of pus draining from the site. If this occurs, notify your doctor. An infected incision may require treatment with antibiotics.
A low-grade fever is fairly common during the first few weeks at home. If your fever is over 100ºF, if it persists, or if you develop shaking chills, this may be a sign of infection. Let your doctor know.
You probably will not be permitted to drive for about six weeks (you may ride as a passenger in a car at any time, however). Driving is temporarily restricted for two reasons: to protect your breastbone as it heals, and to allow your reflexes (slowed after surgery) to return to normal.
Drive only when you have recovered full coordination and are experiencing little pain. Do not drive after taking pain medication. Always use seat belts!
Caring for your Incisions
If your healing is normal, you will probably be permitted to shower at home. Wash your incisions gently with warm (not hot) water and mild soap, then pat them dry with a towel. Do not scrub the incisions.
- Do not apply lotions, creams, or powders to the incisions until healing is complete and scabs have come off.
- If strips of tape have been placed on your incisions, you may remove them gently several days after going home.
- It is fairly common for the leg from which the vein was removed to swell. Your doctor may recommend surgical stockings that support the leg and reduce swelling.
- To help prevent swelling, elevate the leg as often as possible. When sitting, place the leg on a chair that is facing you or lie down flat, several times a day, with the leg supported on a couple of pillows.
- Call your doctor if you develop problems at your incision sites, such as increased soreness, redness, swelling or drainage.
Your Activity Program
Before you leave the hospital, your doctor or nurse will tell you what types of activities you can do at home. Your activity program will depend on several factors, including your medical condition, the state of your recovery and your fitness level.
Walking is the best form of exercise during the early stages of recovery. It's likely you will be advised to walk once or twice a day, for a total of 20 to 30 minutes each day.
Gradually, you may take longer walks. By six weeks, you should be walking for about one hour each day over a distance of around three miles.
The First Few Weeks
- You may feel tired during the first few weeks after your surgery. Little by little, you will gain more energy and strength.
- Increase activities gradually. Slow down or stop when you feel tired. Alternate your activities with periods of rest.
- Light walking is a good activity during early recovery. Avoid walking uphill, against a cold wind, or on hot and humid days.
- Remember that it takes four to six weeks for the breastbone to heal. Avoid putting too much strain on it during the healing process.
- Avoid lifting more than ten pounds for the first six weeks. This includes carrying children, pets, groceries, suitcases, etc.
- For the first few weeks, do light housework only, such as preparing meals, washing dishes and dusting. Avoid vacuuming, gardening and mowing the lawn.
- For recreation, you may participate in card games, board games and arts and crafts. Avoid golf, tennis and bowling.
- Ask your doctor before making travel plans. Travel should be leisurely and relaxed. Do not carry heavy luggage.
You may resume sexual relations when you feel physically comfortable, usually about two to three weeks after you leave the hospital.
Do not begin sex within two hours after a large meal. It is best to pick a time when you are not tired or under stress. Choose positions that require less effort and put less strain on the breastbone, such as laying side-by-side or active partner on top. Try to avoid supporting your body weight on your arms.
Stop sexual activity if you begin to experience chest discomfort, shortness of breath, palpitations or dizziness. Wait for symptoms to go away before you resume activity.
Recovering from bypass surgery is an emotional as well as a physical process. The stress of surgery, lack of sleep, and medications can all have an effect on your emotions.
You may have days during your recovery when you feel discouraged, frustrated or even depressed. This is normal after any major surgery. Remember that these feelings are only temporary and that emotional healing will take place.
You can help yourself get through such bad days by talking out your problems with a loved one or by engaging in activities that you enjoy. If the problems do not seem to go away, talk with your doctor.
Returning to work
If you have a desk job, you should be able to go to work in four to six weeks after surgery. If you have a more physical job, you may need to wait six to eight weeks, or longer. Your doctor can advise you about the best plan for returning to work.
Changes in Lifestyle
Certain conditions and habits, called risk factors, can lead to further build-up of fatty deposits in your coronary arteries and bypass grafts. People who smoke or have high blood cholesterol, for example are more likely to have a heart attack.
If you smoke–quit!
If you have been unable to stop smoking on your own, you may want to join a smoking cessation program. You will be given brochures, audio or video tapes, and kits that will assist you in quitting.
Enjoy a Heart-Healthy Diet
Excess cholesterol in the blood tends to build up on the walls of arteries and can lead to heart disease. A diet high in saturated fats and cholesterol tends to raise your blood cholesterol level.
You can lower your cholesterol level by changing the kind of foods you eat. Cut down on fat, especially saturated fats. Foods that contain a lot of saturated fats include fatty cuts of meat, sausage, whole milk, cream and cheese. Choose foods rich in starch and fiber, such as whole grains, cereals, pasta and rice, dried beans and peas and fresh fruits and vegetables.
When you go grocery shopping, choose foods that are low in fat, such as fresh fruits and vegetables, bread, cereals, low-fat dairy products, fish, chicken and lean cuts of red meat.
Choose cooking methods that use little or no fat, such as steaming, baking, broiling and grilling. Trim off all visible fat before cooking your meat. Lose extra weight. Choose a variety of nutritious foods and go easy on foods that contain lots of calories, such as snacks, desserts and fatty cuts of meat. Eat smaller portions of all foods in your diet.
About two to three months after your bypass surgery, you may be ready to add more strenuous exercises to your routine. Consult your doctor first.
Types of exercise that are good for the heart include brisk walking, jogging, swimming, bicycling, singles tennis, aerobic workouts and dancing.
Making these changes in your lifestyle and following your doctor's instructions are essential for getting the most long-term benefit from your bypass surgery.