What Is Coronary Artery Bypass Grafting?

Coronary artery bypass grafting (CABG) is a type of surgery called revascularization (re-VAS-kyu-lar-i-ZA-shun), used to improve blood flow to the heart in people with severe coronary artery disease (CAD).

CAD occurs when the arteries that supply blood to the heart muscle (the coronary arteries) become blocked due to the buildup of a material called plaque (plak) on the inside of the blood vessels. If the blockage is severe, chest pain (also called angina), shortness of breath, and, in some cases, heart attack can occur.

CABG is one treatment for CAD. During CABG, a healthy artery or vein from another part of the body is connected, or grafted, to the blocked coronary artery. The grafted artery or vein bypasses (that is, it goes around) the blocked portion of the coronary artery. This new passage routes oxygen-rich blood around the blockage to the heart muscle. As many as four major blocked coronary arteries can be bypassed during one surgery.

Overview

CABG is the most common type of open-heart surgery in the United States, with more than 500,000 surgeries performed each year. Doctors called cardiothoracic (KAR-de-o-tho-RAS-ik) surgeons perform this surgery.

CABG isn’t used for everyone with CAD. Many people with CAD can be treated by other means, such as lifestyle changes, medicines, and another revascularization procedure called angioplasty.

CABG may be an option if you have severe blockages in the large coronary arteries that supply a major part of the heart muscle with blood—especially if the heart’s pumping action has already been weakened.

CABG may also be an option if you have blockages in the heart that can’t be treated with angioplasty. In these situations, CABG is considered more effective than other types of treatment.

If you’re a candidate for CABG, the goals of having the surgery are to:

• Improve your quality of life and decrease angina and other symptoms of CAD
• Resume a more active lifestyle
• Improve the pumping action of the heart if it has been damaged by a heart attack
• Lower the chances of a heart attack (in some patients, such as those with diabetes)
• Improve your chance of survival

Repeat surgery may be needed if grafted arteries or veins become blocked, or if new blockages develop in arteries that weren’t blocked before. Taking medicines as prescribed and making lifestyle changes that your doctor recommends can lower the chance of a graft becoming blocked.

In people who are candidates for the surgery, the results are usually excellent, with 85 percent of people having significantly reduced symptoms, less risk for future heart attacks, and a decreased chance of dying within 10 years following the surgery.

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Types of Coronary Artery Bypass Grafting

Traditional Coronary Artery Bypass Grafting

This is the most common type of coronary artery bypass grafting (CABG). It’s used when at least one major artery needs to be bypassed. During the surgery, the chest bone is opened to access the heart. Medicines are given to stop the heart, and a heart-lung machine is used to keep blood and oxygen moving throughout the body during surgery. This allows the surgeon to operate on a still heart. After surgery, the heart is restarted using mild electric shocks.

Off-Pump Coronary Artery Bypass Grafting

This type of CABG is similar to traditional CABG in that the chest bone is opened to access the heart. However, the heart isn’t stopped, and a heart-lung machine isn’t used. Off-pump CABG is sometimes called beating heart bypass grafting. This type of surgery may reduce complications that can occur when a heart-lung machine is used, and it may speed up recovery time after surgery.

Minimally Invasive Direct Coronary Artery Bypass Grafting

This surgery is similar to off-pump, but instead of a large incision to open the chest bone, several small incisions are made on the left side of the chest between the ribs. This type of surgery is used mainly for bypassing the vessels in front of the heart. It’s a fairly new procedure, which is performed less often than the other types. This type of surgery is not for everybody, especially if more than one or two coronary arteries need to be bypassed.

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Other Names for Coronary Artery Bypass Grafting

• Bypass surgery
• Coronary artery bypass surgery
• Heart bypass surgery

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Who Needs Coronary Artery Bypass Grafting?

Coronary artery bypass grafting (CABG) is only used to treat people who have severe coronary artery disease (CAD) that could lead to a heart attack.

Your doctor may recommend CABG if other treatments, such as lifestyle changes or medicines, haven’t worked. He or she also may recommend CABG if you have severe blockages in the large coronary arteries that supply a major part of the heart muscle with blood—especially if your heart’s pumping action has already been weakened.

CABG also may be a treatment option if you have blockages in the heart that can’t be treated with angioplasty.

Your doctor will determine if you’re a candidate for CABG based on a number of factors. These include the presence and severity of CAD symptoms, the severity and location of blockages in your coronary arteries, your response to other treatments, your quality of life, and any other medical problems you may have.

In some cases, CABG may be performed on an emergency basis, such as pending or during a heart attack.

Physical Exam and Diagnostic Tests

To determine if you’re a candidate for CABG, your doctor will do a physical exam that involves checking your cardiovascular system, focusing on heart, lungs, and pulse. Your doctor also will ask you about any symptoms you have, such as chest pain or shortness of breath, and how long, how often, and how severe they are.

Medical tests will be done to find out which arteries are clogged, how much they’re clogged, and whether there’s any heart damage. Tests may include:

• EKG (electrocardiogram). An EKG is a simple test that detects and records the electrical activity of the heart. This test is used to help detect and locate the source of heart problems. An EKG shows how fast the heart is beating, whether the heart’s rhythm is steady or irregular, where in the heart the electrical activity starts, and whether the electrical activity is traveling through the heart in a normal way.
• Stress test. Some heart problems are easier to diagnose when your heart is working harder and beating faster than when it’s at rest. During stress testing, you exercise (or are given medicine if you’re unable to exercise) to make your heart work harder and beat faster while heart tests are performed.

  During exercise stress testing, your blood pressure and EKG readings are monitored while you walk or run on a treadmill or pedal a bicycle. Other heart tests, such as nuclear heart scanning or echocardiography, also can be done at the same time. These would be ordered if your doctor needs more detailed information on blood flow and the heart’s pumping action than the exercise stress test can provide.

  If you are unable to exercise, a medicine can be injected through an intravenous line (IV) into your bloodstream to make your heart work harder and beat faster, as if you are exercising on a treadmill or bicycle. Nuclear heart scanning or echocardiography is then usually done.

  During nuclear heart scanning, radioactive tracer is injected into your bloodstream, and a special camera shows the flow of blood through your heart and arteries. Echocardiography uses sound waves to show blood flow through the chambers and valves of your heart and to show how well your heart pumps.

  Your doctor also may order two newer tests along with stress testing if more information is needed about how well your heart works. These new tests are magnetic resonance imaging (MRI) and positron emission tomography (PET) scanning of the heart. MRI shows detailed images of the structures and beating of your heart, which may help your doctor better assess if parts of your heart are weak or damaged. PET scanning shows the level of metabolic activity in different areas of your heart. This can help your doctor determine if enough blood is flowing to the areas of your heart. A PET scan can show decreased blood flow caused by disease or damaged muscles that may not be detected by other scanning methods.

• Echocardiogram. This test uses sound waves to create a moving picture of your heart. Echocardiogram provides information about the size and shape of your heart and how well your heart chambers and valves are functioning. The test also can identify areas of poor blood flow to the heart, areas of heart muscle that are not contracting normally, and previous injury to the heart muscle caused by poor blood flow.

  There are several different types of echocardiograms, including a stress echocardiogram. During this test, an echocardiogram is done both before and after your heart is stressed either by having you exercise or by injecting a medicine into your bloodstream that makes your heart beat faster and work harder. A stress echocardiogram is usually done to find out if you have decreased pumping action of your heart (CAD).

• Angiography. Angiography uses a special dye injected into the bloodstream to outline the insides of arteries on x-ray pictures. An angiogram shows the location and severity of blockages in blood vessels.

Other Considerations

When deciding if you’re a candidate for CABG, you doctor will also consider your:

• History and past treatment of heart disease, including surgeries, procedures, or medicines
• History of other diseases and conditions
• Age and general health
• Family history of CAD, heart attack, or other heart diseases

Medicines and other medical procedures may be tried before CABG. Medicines that lower cholesterol levels and blood pressure and improve blood flow through the coronary arteries are often tried.

A procedure called coronary angioplasty (also called balloon angioplasty) may be tried. During this procedure, a thin tube with a balloon or other device on the end is threaded through a blood vessel in your groin (upper thigh) or arm up to the narrowed or blocked coronary artery. Once in place, the balloon is inflated to push the plaque against the wall of the artery, widening the artery and restoring the flow of blood through it. In many cases, after the initial balloon angioplasty, a tiny mesh tube called a stent is inserted permanently in the area to keep the artery open.

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What To Expect Before Coronary Artery Bypass Grafting

Tests may be done to prepare you for coronary artery bypass grafting, including blood tests, EKG, echocardiogram, chest x ray, cardiac catheterization, and angiography.

Your doctor will give you specific instructions about how to prepare for surgery. There will be instructions about what to eat or drink, what medicines to take, and what activities to stop (such as smoking). You will likely be admitted to the hospital on the same day as the surgery.

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What To Expect During Coronary Artery Bypass Grafting

Coronary artery bypass grafting (CABG) requires a team of experts. A cardiothoracic surgeon performs the surgery with support from an anesthesiologist, perfusionist (heart-lung machine specialist), other surgeons, and nurses.

There are several different types of CABG. They range from traditional surgery in which the chest is opened to reach the heart, to a nontraditional surgery in which small incisions are made to bypass the narrowed artery.

Traditional Coronary Artery Bypass Grafting

This type of surgery usually lasts 3 to 5 hours, depending on the number of arteries being bypassed. Numerous steps take place during traditional CABG.

Anesthesia is given to put you to sleep. During the surgery, the anesthesiologist monitors your heartbeat, blood pressure, oxygen levels, and breathing. A breathing tube is placed in your lungs through your throat, and connected to a ventilator (breathing machine).

An incision is made down the center of your chest. The chest bone is then cut and your ribcage is opened so that the surgeon can get to your heart.

Medicines are used to stop your heart, which allows the surgeon to operate on it while it’s not beating. A heart-lung machine keeps oxygen-rich blood moving throughout your body. An artery or vein is taken from a different part of your body, such as your chest or leg, and prepared to be used as a graft for the bypass. In surgery with several bypasses, a combination of both artery and vein grafts is commonly used.

• Artery grafts. These grafts are much less likely than vein grafts to become blocked over time. The left internal mammary artery is most commonly used for an artery graft. It’s located inside the chest close to the heart. Arteries from the arm or other places in the body are sometimes used as well.
• Vein grafts. Although veins are commonly used as grafts, they’re more likely than artery grafts to develop plaque and become blocked over time. The saphenous vein—a long vein running along the inner side of the leg—is typically used.

After the grafting is complete, your heart is restarted using mild electric shocks. You’re disconnected from the heart-lung machine. Tubes are inserted into your chest to drain fluid.

The surgeon uses wires that stay in your body permanently to close your chest bone and stitches or staples to close the skin incision. The breathing tube is removed when you’re able to breathe without it.

Nontraditional Coronary Artery Bypass Grafting

Nontraditional CABG includes off-pump CABG and minimally invasive CABG.

Off-Pump Coronary Artery Bypass Grafting

This type of surgery can be used to bypass any of the coronary arteries. Off-pump CABG also is called beating heart bypass grafting because the heart isn’t stopped and a heart-lung machine isn’t used. Instead, the part of the heart where grafting is being done is steadied with a mechanical device.

Off-pump CABG may reduce complications that can occur when a heart-lung machine is used, especially in people who have had a stroke or “mini-strokes� in the past, who are over age 70, and who have diabetes, lung disease, or kidney disease.

Other advantages of this type of bypass surgery include:

• Reduced bleeding during surgery and a lower chance of needing a blood transfusion
• A lower chance of infection, stroke, and kidney complications
• A lower chance of complications such as memory loss, difficulty concentrating, or difficulty thinking clearly
• Faster recovery from the surgery

Minimally Invasive Direct Coronary Artery Bypass Grafting

There are several types of minimally invasive direct coronary artery bypass (MIDCAB) grafting. These types of surgery differ from traditional bypass surgery because they only require small incisions rather than opening the chest bone to get to the heart. These procedures sometimes use a heart-lung machine.

MIDCAB procedure. This procedure is used when only one or two coronary arteries need to be bypassed. A series of small incisions is made between your ribs on the left side of your chest, directly over the artery to be bypassed. The incisions are usually about 3 inches long. (The incisions made in traditional CABG are at least 6 to 8 inches long.) The left internal mammary artery is most often used for the graft. A heart-lung machine isn’t used during this procedure.

Port-access coronary artery bypass procedure. This procedure is performed through small incisions (ports) made in your chest. Artery or vein grafts are used. The heart-lung machine is used during this procedure.

Robot-assisted technique. This type of procedure allows for even smaller, keyhole-sized incisions. A small video camera is inserted in one incision to show the heart, while the surgeon uses remotely controlled surgical instruments to perform the surgery. The heart-lung machine is sometimes used during this procedure.

Advantages of minimally invasive CABG include smaller incisions, smaller scars, shorter recovery and hospital stay, less bleeding, less chance for infection, and less pain.

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What To Expect After Coronary Artery Bypass Grafting

Recovery in the Hospital

After surgery, you will typically spend 1 or 2 days in an intensive care unit. Your heart rate and blood pressure will be continuously monitored during this time. Intravenous medicines (medicines injected through a vein) are often given to regulate blood circulation and blood pressure. You will then be moved to a less intensive care area of the hospital for 3 to 5 days before going home.

Recovery at Home

Your doctor will give you specific instructions for recovering at home, especially concerning:

• How to care for your healing incisions
• How to recognize signs of infection or other complications
• When to call the doctor immediately
• When to make followup appointments

You may also receive instructions on how to deal with common after-effects from surgery. After-effects often go away within 4 to 6 weeks after surgery, but may include:

• Discomfort or itching from healing incisions
• Swelling of the area where an artery or vein was taken for grafting
• Muscle pain or tightness in the shoulders and upper back
• Fatigue (tiredness), mood swings, or depression
• Difficulty sleeping or loss of appetite
• Constipation
• Chest pain around the site of the chest bone incision (more frequent with the traditional surgery)

Full recovery from traditional CABG may take 6 to 12 weeks or more. Less recovery time is needed for nontraditional CABG.

Your doctor will provide instructions on resuming physical activity. This varies from person to person, but there are some typical timeframes. Most people can resume sexual activity within about 4 weeks and driving after 3 to 8 weeks.

Returning to work after 6 weeks is common unless the job involves specific and demanding physical activity. Some people may need to find less physically demanding types of work or work a reduced schedule at first.

Ongoing Care

Care after surgery may include periodic checkups with doctors. During these visits, tests may be done to see how the heart is working. Tests may include EKG, stress testing, and echocardiogram.

CABG is not a cure for coronary artery disease (CAD). You and your doctor may develop a management plan that includes lifestyle changes to help you stay healthy and reduce the chances of CAD getting worse. Lifestyle changes may include quitting smoking, making changes in your diet, getting regular exercise, and lowering and managing stress.

In some cases, your doctor may refer you to a cardiac rehabilitation (rehab) program. These programs can help you recover through supervised physical activity and education on how to make choices that reduce your risk for future heart problems and help you get back to your regular lifestyle after surgery.

Doctors supervise these programs, which include counseling about lifestyle changes as well as exercise training to build strength and energy. Cardiac rehab programs may be offered in hospitals and other community facilities. Ask your doctor whether you’re a candidate for cardiac rehab.

Taking medicines as prescribed also is an important part of care after surgery. Medicines may be prescribed to manage pain during recovery; lower cholesterol, blood pressure, and the chance of developing blood clots; manage diabetes; or treat depression.

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What Are the Risks of Coronary Artery Bypass Grafting?

Although complications from coronary artery bypass grafting (CABG) are uncommon, the risks include:

• Wound infection and bleeding
• Anesthesia reactions
• Fever
• Pain
• Stroke, heart attack, or even death

Some patients can develop a fever associated with chest pain, irritability, and decreased appetite. This is due to inflammation involving the lung and heart sac, and is sometimes seen 1 to 6 weeks after surgeries that involve cutting through the pericardium (the outer covering of the heart). This reaction is usually a mild, self-limited illness, but some patients may develop fluid buildup around the heart that requires treatment.

Use of the heart-lung machine also can cause complications. Memory loss and other changes, such as difficulty concentrating or thinking clearly, may occur in some people. These changes are more likely to occur in people who are older, who have high blood pressure or lung disease, or who drink excessive amounts of alcohol. These side effects often improve several months after surgery.

The heart-lung machine also increases the risk of blood clots forming in your blood vessels. Clots can travel to the brain or other parts of the body and block the flow of blood, which can cause stroke or other problems. Recent technical improvements in heart-lung machines are helping to reduce the risk of blood clots forming.

In general, the chances of developing complications are higher when CABG is done in an emergency situation (for example, if performed during a heart attack), if you’re over age 70, or if you have a history of smoking. Your risks also are higher if you have other diseases or conditions such as diabetes, kidney disease, lung disease, or peripheral vascular disease.

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Key Points

• Coronary artery bypass grafting (CABG) is a type of surgery used to improve blood flow to the heart in people with severe coronary artery disease (CAD).
• During CABG, a healthy artery or vein from another part of the body is connected, or grafted, to a blocked coronary artery. The grafted artery or vein bypasses (that is, it goes around) the blocked portion of the coronary artery. This improves the flow of blood and oxygen to your heart muscle.
• CABG is one type of treatment for CAD. Not everyone with CAD needs CABG. In people who are candidates for the surgery, the results are usually excellent, with 85 percent of people having significantly reduced symptoms, less risk for future heart attacks, and a decreased chance of dying within 10 years following the surgery.
• Your doctor will determine if you’re a candidate for CABG based on a number of factors, including the presence and severity of CAD. Often nonsurgical treatments, such as medicines and angioplasty, will be tried first.
• Although the surgery is usually done on an elective (scheduled) basis, it may need to be performed in an emergency, such as pending or during a heart attack.
• Although complications are rare, risks of CABG include infection at the incision site, bleeding, reactions to the anesthesia, fever and pain, stroke, heart attack, or even death.
• Recovery may take 6 to 12 weeks or more. Most people can get back to their normal activities about 6 weeks after the surgery.
• Care after surgery may include followup visits with doctors, lifestyle changes to prevent further progression of CAD, and taking medicines as prescribed.

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What Is Heart Surgery?

Heart surgery is done to correct problems with the heart. More than half a million heart surgeries are done each year in the United States for a variety of heart problems.

Heart surgery is used to correct heart problems in children and adults. This article discusses heart surgeries for adults. For more information about heart surgeries for children, see the Diseases and Conditions Index articles on congenital heart defects, holes in the heart, and tetralogy of Fallot.

Overview

The most common type of heart surgery for adults is coronary artery bypass grafting (CABG). During CABG, surgeons use healthy arteries or veins taken from another part of the body to bypass (that is, go around) blocked arteries. CABG relieves chest pain and reduces the risk of heart attack.

Heart surgery also is done to:

• Repair or replace valves that control blood flow through the heart
• Repair abnormal or damaged structures in the heart
• Implant medical devices that regulate heart rhythms or blood flow
• Replace a damaged heart with a healthy heart from a donor (heart transplant)

Traditional heart surgery, often called “open heart surgery,” is done by opening the chest wall to operate on the heart. Almost always, the chest is opened by cutting through a patient’s breastbone. Once the heart is exposed, the patient is connected to a heart-lung bypass machine. The machine takes over the pumping action of the heart. This allows surgeons to operate on a still heart.

In recent years, new ways of doing heart surgery have been developed. One new way is called off-pump, or beating heart, surgery. It’s like traditional open-heart surgery, but it doesn’t use a heart-lung bypass machine.

Minimally invasive heart surgery uses smaller incisions (cuts) than traditional open-heart surgery. Some types of minimally invasive heart surgery use a heart-lung bypass machine and others don’t.

These new methods may reduce risks and speed up recovery time. Studies are under way to compare these new types of heart surgery to traditional open-heart surgery. The results of these studies will help doctors decide the best procedure to use for each patient.

Outlook

The results of heart surgery in adults are often excellent. For very ill people with severe heart problems, heart surgery can reduce symptoms, improve quality of life, and increase lifespan.

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Types of Heart Surgery

Different types of heart surgery are used to fix different heart problems.

Coronary Artery Bypass Grafting

Coronary artery bypass grafting (CABG) is the most common type of heart surgery. More than 500,000 of these surgeries are done each year in the United States. CABG improves blood flow to the heart. It’s used for people with severe coronary artery disease (CAD).

In CAD, a fatty material called plaque (plak) builds up inside your coronary (heart) arteries. It narrows the arteries and limits blood flow to your heart muscle. CAD can cause angina (chest pain or discomfort, pronounced an-JI-nuh or AN-juh-nuh), shortness of breath, and can even lead to a heart attack.

During CABG, a surgeon takes a vein or an artery from your chest, your leg, or another part of your body and connects, or grafts, it to the blocked artery. The grafted artery bypasses (that is, goes around) the blockage. This allows oxygen-rich blood to reach the heart muscle. Surgeons can bypass as many as four blocked coronary arteries during one surgery.

Sometimes you can choose between CABG and angioplasty (AN-jee-oh-plas-tee) to treat CAD. Talk to your doctor about these different treatments.

Transmyocardial Laser Revascularization

Transmyocardial (tranz-mi-o-KAR-de-al) laser revascularization (re-VAS-kyu-lar-i-ZA-shun), or TLR, is a surgery used to treat angina when no other treatments work. For example, if you’ve already had one CABG procedure and can’t have another one, TLR may be an option. This type of heart surgery isn’t common.

During TLR, the surgeon uses lasers to make channels in the heart muscle. These channels allow oxygen-rich blood to flow from a heart chamber directly into the heart muscle.

Valve Repair or Replacement

For the heart to work right, blood must flow in only one direction. The heart’s valves make this possible. Healthy valves open and close in a precise way as the heart pumps blood.

Each valve has a set of flaps called leaflets. The leaflets open to allow blood to pass from the heart chambers into the arteries. Then the leaflets close tightly to stop blood from flowing back into the chambers.

Heart surgery is done to fix leaflets that don’t open as wide as they should. This can happen when they become thick or stiff or fuse together. As a result, not enough blood flows through the valve into the artery.

Heart surgery also is done to fix leaflets that don’t close tightly. This means blood can leak backward into the chambers, rather than only moving forward into the artery as it should.

To fix these problems, surgeons either repair the valve or replace it. Replacement valves are taken from animals, made from human tissue, or made from man-made substances.

Arrhythmia Treatment

An arrhythmia (ah-RITH-me-ah) is a problem with the speed or rhythm of the heartbeat. During an arrhythmia, the heart can beat too fast, too slow, or with an irregular rhythm.

Most arrhythmias are harmless, but some can be serious or even life threatening. When the heart rate is abnormal, the heart may not be able to pump enough blood to the body. Lack of blood flow can damage the brain, heart, and other organs.

Arrhythmias are usually treated with medicine first. If medicines don’t work well enough, you may need surgery. For example, your doctor may use surgery to give you a pacemaker or an implantable cardioverter defibrillator (ICD).

A pacemaker is a small device that’s placed under the skin of your chest or abdomen. Wires lead from the pacemaker to the heart’s chambers. The pacemaker sends electrical signals through the wires to control the speed of the heartbeat. Most pacemakers have a sensor that activates the device only when the heartbeat is abnormal.

An ICD is another small device that’s placed in your chest or abdomen. This device also is connected to the heart with wires. It checks your heartbeat for dangerous arrhythmias. If it senses one, it sends an electric shock to the heart to restore a normal heartbeat.

Another type of surgery for arrhythmia is called Maze surgery. In this operation, the surgeon makes new paths (a maze) for the heart’s electrical signals to travel through. This type of surgery is used to treat atrial fibrillation, the most common type of serious arrhythmia.

Aneurysm Repair

An aneurysm (AN-u-rism) is an abnormal bulge or “ballooning” in the wall of an artery or the heart muscle. This bulge happens when the wall weakens. Pressure from blood moving through the artery or heart causes the weak area to bulge out. Over time an aneurysm can grow and can burst, causing dangerous, often fatal bleeding inside the body.

Aneurysms in the heart most often occur in the heart’s lower left chamber. They can develop after a heart attack.

Repairing an aneurysm involves surgery to replace the weak section of the artery or heart wall with a patch or graft.

Ventricular Assist Devices

Ventricular assist devices (VADs) are mechanical pumps that support your heart or take over your heart’s pumping action. VADs are used when your heart can’t pump enough blood to support your body.

You may need a VAD if you have heart failure or if you’re waiting for a heart transplant. You can use a VAD for a short time or for months or years, depending on your situation.

Heart Transplant

A heart transplant is surgery in which a diseased heart is replaced with a healthy heart from a deceased donor. Heart transplants are done on patients whose hearts are so damaged or weak that they can’t pump enough blood to meet the body’s needs.

This type of surgery is a life-saving measure that’s used when medical treatment and less drastic surgery have failed.

Because donor hearts are in short supply, patients who need a heart transplant go through a careful selection process. They need to be sick enough to need a new heart, yet healthy enough to receive it.

Patients on the waiting list for a donor heart receive ongoing treatment for heart failure and other medical conditions. VADs may be used to treat these patients.

Surgical Approaches

In recent years, new ways of doing heart surgery have been developed. Depending on a patient’s heart problem, general health, and other factors, he or she can now have open-heart surgery or minimally invasive heart surgery.

Open-Heart Surgery

Open-heart surgery is any kind of surgery where the chest wall is opened and surgeons operate on the heart. “Open” refers to the chest, not the heart. Depending on the type of surgery, the heart may be opened too.

Open-heart surgery is used to bypass blocked arteries in the heart, repair or replace heart valves, fix atrial fibrillation, and transplant hearts.

In recent years, more surgeons have started to use off-pump, or beating heart, surgery to do CABG. This approach is like traditional open-heart surgery, but surgeons don’t use a heart-lung bypass machine.

Off-pump heart surgery may reduce complications that can occur when a heart-lung bypass machine is used. It also may speed up recovery time.

Off-pump heart surgery isn’t right for all patients. Your doctor will decide whether you should have this type of surgery. He or she will carefully consider your heart problem, age, overall health, and other factors that may affect the surgery.

Minimally Invasive Heart Surgery

For minimally invasive heart surgery, a surgeon doesn’t make a large incision (cut) down the center of the chest to open the rib cage. Instead, he or she makes small incisions in the side of the chest between the ribs.

A heart-lung bypass machine is used in some types of minimally invasive heart surgery, but not others.

This newer heart surgery is used for some CABG and Maze procedures. It’s also used to repair or replace heart valves and insert pacemakers.

One type of minimally invasive heart surgery that’s still being developed is robotic-assisted surgery. For this surgery, a surgeon uses a computer to control surgical tools on thin robotic arms. The tools are inserted through small incisions in the chest. This allows surgeons to perform complex and highly precise surgery. The surgeon is always in total control of the robotic arms; they don’t move on their own.

Benefits of minimally invasive heart surgery compared to open-heart surgery include smaller incisions and scars, lower risk of infection, less pain, a shorter hospital stay, and a faster recovery.

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Who Needs Heart Surgery?

Heart surgery is used to treat people who have severe heart diseases and conditions. If other treatments, such as lifestyle changes, medicines, and medical procedures, haven’t worked or can’t be used, heart surgery may be an option.

Heart surgery is used to treat heart failure and coronary artery disease. It’s also used to fix heart valves that don’t work right, to regulate heart rhythms, and to replace a damaged heart with a healthy one.

Specialists Involved

Your primary care doctor, a cardiologist, and a cardiothoracic (KAR-de-o-tho-RAS-ik) surgeon will decide whether you need heart surgery. A cardiologist specializes in treating heart problems. A cardiothoracic surgeon specializes in surgery on the heart and lungs.

These doctors will talk with you and do tests to learn about your general health and your heart problem. They’ll discuss test results with you, and you will help make decisions about the surgery.

Medical Evaluation

Your doctors will talk with you about:

• The kind of heart problem you have, the symptoms it’s causing, and how long you have had symptoms
• Your history and past treatment for heart problems, including surgeries, procedures, and medicines
• Your family’s history of heart problems
• Your history of other health problems and conditions, such as diabetes or high blood pressure
• Your age and general health

The doctors also may do blood tests, such as a complete blood count, a cholesterol test, and other tests as needed.

Diagnostic Tests

Medical tests are done to find out more about your heart problem and your general health. This helps your doctors decide whether you need heart surgery, what type of surgery you need, and when to do it.

EKG (Electrocardiogram)

An EKG is a simple and painless test that records the electrical activity of your heart. This test is used to help detect and locate the source of heart problems.

A technician attaches sticky patches, called electrodes, to the skin of your chest, arms, and legs. The electrodes are attached with wires to a machine that records your heart’s electrical signals.

An EKG shows how fast your heart is beating and whether its rhythm is steady or irregular. It also shows where in your heart the electrical activity starts, and whether it’s traveling through your heart in a normal way.

Stress Test

Some heart problems are easier to diagnose when your heart is working harder and beating faster than when it’s at rest. During stress testing, you exercise (or are given medicine if you’re unable to exercise) to make your heart work hard and beat fast.

During the stress test, your blood pressure is checked and an EKG is done. Other heart tests also may be performed.

Echocardiography

Echocardiography is a painless, noninvasive test. “Noninvasive” means that no surgery is done and no instruments are inserted into your body.

This test uses sound waves to create a moving picture of your heart. Echocardiography provides information about the size and shape of your heart and how well your heart chambers and valves are working.

The test also can show areas of poor blood flow to your heart, areas of heart muscle that aren’t contracting normally, and previous injury to your heart muscle caused by poor blood flow.

Coronary Angiography

Coronary angiography (an-jee-OG-ra-fee) uses a special dye to show the insides of your coronary arteries on x-ray pictures. An angiogram shows the location and severity of blockages in blood vessels.

To get the dye to your coronary arteries, a procedure called cardiac catheterization (KATH-e-ter-i-ZA-shun) is used. Cardiologists usually do cardiac catheterizations in a hospital. You’re awake during the procedure, and it usually causes little to no pain.

During this procedure, a catheter (a thin, flexible tube) is passed through an artery in your leg or arm and threaded to your heart. The dye is injected into your bloodstream through the tip of the catheter.

Aortogram

An aortogram is an angiogram of the aorta. The aorta is the main artery that carries blood from your heart to your body. An aortogram may show the location and size of an aortic aneurysm and the arteries that are involved.

Chest X Ray

A chest x ray provides a picture of the organs and structures inside your chest, including the heart, lungs, and blood vessels. This test gives your doctor information about the size and shape of your heart. A chest x ray also shows the position and shape of the large arteries around your heart.

Cardiac Computed Tomography Scan

A cardiac computed tomography (CT) scan provides computer-generated, x-ray images of your internal organs. A liquid dye that can be seen on an x ray is injected into a vein in your arm. The dye outlines arteries and veins in your heart on the CT scan.

A cardiac CT scan can show whether plaque is narrowing your coronary arteries or whether you have an aneurysm. A CT scan also can find problems with heart function and heart valves.

Cardiac Magnetic Resonance Imaging

Cardiac magnetic resonance imaging (MRI) is a safe and noninvasive test that uses magnets and radio waves to create images of the inside of your body.

Cardiac MRI uses a computer to create images of your heart as it’s beating. The computer makes both still and moving pictures of your heart and major blood vessels.

Cardiac MRI shows the structure and function of your heart. This test is very accurate at finding aneurysms and determining their size and exact location.

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What To Expect Before Heart Surgery

There are many types of heart surgery. The type you need depends on your situation. One person’s experience before an operation can be very different from another’s.

Some people carefully plan their surgeries with their doctors. They know exactly when and how it will happen. Other people need emergency heart surgery. Others are diagnosed with blocked coronary arteries and are admitted to the hospital right away for surgery as soon as possible.

If you’re having a planned surgery, you may be admitted to the hospital the afternoon or morning before your surgery. Your doctors and others on your health care team will meet with you to explain what will happen. They will give you instructions on how to prepare for the surgery.

You also may need to have some tests, such as an EKG (electrocardiogram), chest x ray, or blood tests. An intravenous (IV) line will be placed in your arm to give you fluids and medicines. Hair near the incision site may be shaved. Your skin may be washed with special soap to reduce the risk of infection.

Just before the surgery, you will be moved to the operating room. You will be given medicine so that you fall asleep and feel no pain during the surgery.

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What To Expect During Heart Surgery

Heart surgery is done in a hospital. A team of experts is involved. Cardiothoracic surgeons perform the surgery with a team of other doctors and nurses who assist.

The length of time for the surgery depends on the type of surgery. CABG, the most common type of heart surgery, usually takes 3 to 5 hours.

Traditional Open-Heart Surgery

For this type of surgery, you’re given medicine to make you fall asleep. A doctor checks your heartbeat, blood pressure, oxygen levels, and breathing during the surgery. A breathing tube is placed in your lungs through your throat and connected to a ventilator (breathing machine).

A surgeon makes a 6- to 8-inch incision (cut) down the center of your chest wall. Your chest bone is cut and your rib cage is opened so that the surgeon can get to your heart.

You’re given medicine to thin your blood and keep it from clotting. A heart-lung bypass machine is connected to your heart. This machine takes over for your heart by replacing the heart’s pumping action. A specialist oversees the machine. The bypass machine allows the surgeon to operate on a heart that isn’t moving and full of blood.

Heart-Lung Bypass Machine

The illustration shows a heart-lung bypass machine attached to a heart during surgery.

You’re given medicines to stop your heartbeat once you’re connected to the heart-lung bypass machine. A pipe is placed in your heart to drain blood to the machine. The machine removes carbon dioxide (a waste product) from your blood, adds oxygen, and then pumps the blood back into your body. Tubes are inserted into your chest to drain fluid.

Once the bypass machine begins to work, the surgeon performs the surgery to repair your heart problem.

At the end of the surgery, your heart is restarted using mild electric shocks. The pipes and tubes are removed from your heart, and the heart-lung bypass machine is stopped. You’re given medicine to allow your blood to clot again.

Your chest bone is closed with wires. Stitches or staples are used to close the incision. The breathing tube is removed.

An advantage of traditional open-heart surgery is that it’s easier for the surgeon to operate. This is very important for long and complex surgeries.

Off-Pump Heart Surgery

This type of surgery is the same as traditional open-heart surgery, except you aren’t connected to a heart-lung bypass machine. Instead, your heart is steadied with a mechanical device while the surgeon works on it. Your heart continues to pump blood to your body.

The advantages of off-pump heart surgery are:

• No complications related to using a heart-lung bypass machine
• Faster recovery from the surgery

Minimally Invasive Heart Surgery

For this type of heart surgery, the surgeon makes small incisions in the side of your chest between the ribs. These incisions can be as small as 2 to 3 inches. Then the surgeon inserts surgical tools through these small incisions. A tool with a small video camera at the tip also is inserted through an incision. This allows the surgeon to see inside the body.

Some types of minimally invasive heart surgery use a heart-lung bypass machine; other types don’t.

The advantages of minimally invasive heart surgery are:

• Less bleeding during surgery and a lower chance of needing a blood transfusion
• Lower risk of infection
• Less pain
• Smaller incisions and scars
• A shorter hospital stay and faster recovery

Patients who don’t need the heart-lung bypass machine aren’t at risk for the complications that the machine may cause.

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What To Expect After Heart Surgery

Recovery in the Hospital

Depending on the type of heart surgery, you may spend 1 day or more in the hospital’s intensive care unit. Then you will be moved to another part of hospital for several days before you go home.

While you’re in the hospital, doctors and nurses will closely watch your heart rate, blood pressure, breathing, vital signs, and incision site(s). You may have an intravenous (IV) needle inserted in your arm to give you fluids until you’re ready to drink on your own.

You also may be given extra oxygen through a face mask or nasal prongs that fit just inside your nose. These pieces of equipment are removed when you don’t need them any more.

Recovery at Home

Each person responds differently to heart surgery. Your recovery at home also will depend on what kind of heart problem and surgery you had. Your doctor will give you specific instructions about how to:

• Care for your healing incisions
• Recognize signs of infection or other complications
• Cope with after-effects of surgery

You also will get information about followup appointments, medicines, and situations when you should call the doctor right away.

After-effects of heart surgery are normal. They may include:

• Muscle pain
• Chest pain
• Swelling (especially if you have an incision in your leg from coronary artery bypass grafting, or CABG)

Other after-effects may include loss of appetite, difficulty sleeping, constipation, and mood swings and depression. After-effects gradually go away.

Recovery time varies with type of heart surgery. Full recovery from traditional open-heart CABG may take 6 to 12 weeks or more. Less recovery time is needed for off-pump heart surgery and minimally invasive heart surgery.

Your doctor will let you know when you can go back to your daily activities, such as working, driving, and physical activity.

Ongoing Care

Care after your surgery may include periodic checkups with your doctor. During these visits, you may have blood tests, an EKG (electrocardiogram), an echocardiography, or a stress test. These tests will show how your heart is working after the surgery.

Your doctor also may talk to you about lifestyle changes and medicines to help you stay healthy. Lifestyle changes may include quitting smoking, making changes in your diet, getting regular physical activity, and lowering and managing stress.

You doctor may refer you to a cardiac rehabilitation (rehab) program. Cardiac rehab includes counseling, education, and exercise training to help you recover. The program also will help you learn how to make choices that can lower your risk for future heart problems.

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What Are the Risks of Heart Surgery?

Heart surgery has risks, even though its results often are excellent. Risks can be from the surgery itself or from the heart-lung bypass machine. They include:

• Bleeding.
• Infection, fever, swelling, and other signs of inflammation.
• Reaction to the medicine used to make you sleep.
• Arrhythmias (irregular heartbeats).
• Memory loss and difficulty concentrating or thinking clearly.
• Damage to tissues in the heart, kidneys, and lungs.
• Death. (People who are very sick before the surgery are at higher risk.)

In general, the risks of heart surgery are higher for people who:

• Are older than 70
• Have had previous heart surgery
• Have diseases or conditions such as high blood pressure, diabetes, kidney disease, lung disease, or peripheral arterial disease

The use of a heart-lung bypass machine increases the risk of blood clots forming in your blood vessels. Clots can travel to the brain or other parts of the body and block the flow of blood. This can cause stroke or other problems. Recent improvements in heart-lung bypass machines are helping to reduce the risk of blood clots forming.

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Key Points

• Heart surgery is done to correct problems with the heart. More than half a million heart surgeries are done each year in the United States for a variety of heart problems.
• The most common type of heart surgery in adults is coronary artery bypass grafting (CABG). During CABG, surgeons use healthy arteries or veins taken from another part of the body to bypass (that is, go around) blocked arteries.
• Heart surgery also is done to repair or replace valves that control blood flow through the heart, repair structures in the heart, implant devices to regulate heart rhythms, or replace a damaged heart with a healthy heart from a donor.
• Traditional open-heart surgery is done by opening the chest wall to operate on the heart. The patient is connected to a heart-lung bypass machine. This machine takes over the pumping action of the heart, makes sure the blood gets enough oxygen, and allows surgeons to operate on a still heart.
• In recent years, new ways of doing heart surgery have been developed. One new way is off-pump, or beating heart, surgery. This is like traditional open-heart surgery, but it doesn’t use a heart-lung bypass machine. Minimally invasive heart surgery uses smaller incisions (cuts) than traditional open-heart surgery. Some types of minimally invasive heart surgery use a heart-lung bypass machine and others don’t.
• Studies are under way to compare new types of heart surgery to traditional heart surgery.
• Different types of heart surgery are used to fix different heart problems. Heart surgery is used to bypass blocked arteries, repair or replace heart valves, treat arrhythmias (irregular heartbeats), repair aneurysms, treat angina (chest pain or discomfort), and replace a diseased heart with a healthy one.
• Heart surgery is used to treat people who have severe heart diseases and conditions when other treatments have failed.
• Your doctors will determine whether you need heart surgery based on the kind of heart problem you have, your history and past treatment for heart problems, your family’s history of heart problems, whether you have other health conditions, your age, and your general health.
• What happens before, during, and after heart surgery depends on the type of surgery you have. CABG, the most common type of heart surgery, usually takes 3 to 5 hours.
• After surgery, your doctor will let you know how to care for yourself. You may need followup medical care, lifestyle changes, medicines, or cardiac rehabilitation.
• The risks of heart surgery include bleeding, infection, fever, reaction to the medicine used to make you sleep, irregular heartbeats, and death. (The risk of death is higher in people who are already very sick.) Use of a heart-lung bypass machine can cause blood clots to form in your blood vessels and block blood flow.
• The results of heart surgery often are excellent. For very ill people who have severe heart problems, heart surgery can reduce symptoms, improve quality of life, and increase lifespan.

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