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Heart Surgery

The steps leading to one of the most common heart procedures: Coronary Artery Bypass Graft

The Texas Heart Institute reports that, “Thousands of heart surgeries are performed every day in the United States. In fact, in a recent year, surgeons performed 500,000 coronary bypass procedures.” Coronary Artery Bypass Graft (CABG, pronounced “cabbage”) Surgery is the most common procedure performed to bypasses a severely blocked artery in the heart with a healthy blood vessel. This surgery restores vital blood flow to the heart muscle.

Since the late 19th century, surgeons have been performing cardiac surgery. On May 6, 1953, the first successful open-heart operation was performed on an 18-year-old woman in Philadelphia with a heart defect. What was once a new, unknown, scary procedure is now one of the best known, most studied and most effective surgeries of the modern age. Today, more than 95 percent of people who undergo coronary bypass surgery do not experience serious complications, and the risk of death immediately after the procedure is only 1–2 percent. The list of famous bypass recipients includes celebrities like Elizabeth Taylor, David Letterman, and Larry King to former President Bill Clinton and Vice President Dick Cheney.

Even with this reassurance, there are still concerns and questions surrounding bypass surgery. Dr. Lance Sullenberger is board certified in Internal Medicine, Cardiovascular Disease, and Advanced Heart Failure/Transplant Cardiology. He regularly consults his patients on CABG surgeries. “I would say there are two major ways a patient would present the need for an open heart surgery procedure or CABG,” he said. “The first would begin with a visit to your cardiologist.”

Doctors can determine when someone needs open-heart surgery by performing specific tests. This would begin with a patient who presents typical warning signs, chest pain, shortness of breath or palpitations. People with coronary heart disease sometimes experience buildups of plaque — a combination of fat, calcium, cholesterol and other cellular junk — on the insides of their arteries. This can restrict blood flow and cause clots. The most common symptom of a clogged artery is chest pain. In this case, the physician would order a stress test.

Doctors can determine when someone needs open-heart surgery by performing specific tests. This would begin with a patient who presents typical warning signs, chest pain, shortness of breath or palpitations. People with coronary heart disease sometimes experience buildups of plaque — a combination of fat, calcium, cholesterol and other cellular junk — on the insides of their arteries. This can restrict blood flow and cause clots. The most common symptom of a clogged artery is chest pain. In this case, the physician would order a stress test.

Testing

The heart performs differently at rest than it does during exercise. An exercise stress test – also known as a treadmill test – is designed to help your doctor learn how your heart performs during exercise or other activities that would make the heart work harder. For patients that are unable to use a treadmill or to get a deeper look, your doctor could order a nuclear stress test to help in the diagnosis of coronary artery disease or other heart conditions.

If the result of the stress test is abnormal, that patient would then be placed on medication and referred for catheterization, performed by an interventional cardiologist. “They do a diagnostic cardiac catheterization to look at the arteries that supply the heart with blood to see if that stress test was accurate,” noted Dr. Sullenberger. Again, with this test, physicians are looking for buildups that cause blockage of blood flow. Typically, arteries that are not blocked over 60 to 70% would be treated with medical therapy (medications, alterations in diets, changes in sleep habits, increased physical activity, stress reduction and more).

There could be one or maybe two arteries that have a blockage in them. “In that case, the decision would be made whether or not to use medicines or perhaps put stents in,” said Dr. Sullenberger. The stenting procedure could occur at that moment at the time of the catheterization. “When you start dealing with more than two arteries that are blocked or if there are special situations, such as the main artery on the left is blocked then you have to take a step back and ask, ‘Is this somebody who would be better served by stents or by bypass surgery?’ This is when the cardiologist and the cardiac surgeon would meet to discuss the options involved,” he shared.

The other major situation in which the decision has to be made between stenting and bypass is when a patient presents with a heart attack. “They are coming in with chest pain, losing heart muscle, most of those patients end up immediately in the Cath lab where an interventional cardiologist will look to see which artery is blocked and causing the heart attack, at that moment,” says Dr. Sullenberger. Most of those patients will receive a stent at that moment. A stent is a tiny wire mesh tube that is inserted inside a clogged artery through a tube procedure that does not require open-heart surgery. It props open an artery and is left there permanently.

The other major situation in which the decision has to be made between stenting and bypass is when a patient presents with a heart attack. “They are coming in with chest pain, losing heart muscle, most of those patients end up immediately in the Cath lab where an interventional cardiologist will look to see which artery is blocked and causing the heart attack, at that moment,” says Dr. Sullenberger. Most of those patients will receive a stent at that moment. A stent is a tiny wire mesh tube that is inserted inside a clogged artery through a tube procedure that does not require open-heart surgery. It props open an artery and is left there permanently.

For patients who present blocked arteries that cannot be corrected with stenting, Sullenberger states that the patient is stabilized in the coronary care unit while the cardiologist and surgeon meet to discuss the next best step. “Most good cardiologists have an idea beforehand if this person is going to end up needing a bypass or if they have valve disease,” he says. The timeline on when to operate depends on the patient’s condition. For an out-patient, surgery is performed within weeks. For heart attack patients, those decisions are made in a day, 48-hours at the most.

Surgical Procedure

According to the Agency for Healthcare Research and Quality statistical brief, published in March 2014, about 213,700 Americans have a CABG procedure every year. When someone has bypass surgery, they are in the operating room for several hours, on average about six hours. Most of that time is spent prepping the patient and getting them ready. The actual bypass surgery itself is about a two-hour procedure which can go longer or shorter based on what needs to be done.

In a typical procedure, the surgeon harvests a healthy blood vessel from a donor site. This is called a graft. The graft is commonly taken from the patient’s leg or arm. The surgeon opens the patient’s chest to expose the heart. The patient’s blood flow is diverted to a heart-lung machine. This machine temporarily takes over the lung’s function of oxygenating the blood and the heart’s function of pumping blood to the body. Medication is administered to stop the patient’s heart and preserve it during the surgery. After the bypass is complete, the surgeon removes the clamp from the aorta and allows the heart to resume beating on its own. The surgeon may insert a temporary pacing wire. This wire can be connected to a pacemaker if needed.

The patient then goes to a surgical ICU for recovery, made especially for cardiothoracic patients that receive specialized nursing care. That’s when cardiologists would see the patient. “In a best-case scenario,” Sullenberger begins, “you stay in the ICU about 48-hours after surgery, then you go to a step-down floor for another five days or so. Expect about a week in the hospital. Then you are discharged to go home and will follow up with your cardiologist within a week, and the cardiothoracic surgeon within a week or two, then you don’t see your surgeon anymore.” Unless there is a problem, you won’t see your surgeon again, but you will continue to see your cardiologist on a regular appointment basis.

Prevention

The need for CABG surgeries is expected to expand by just over 5% in the seven years due to stress, obesity, sedentary lifestyle, and unhealthy habits. “For everyone [reading this] now, you never want to have to see a cardiologist or a cardiothoracic surgeon. The way you avoid that is doing everything you can to keep a healthy lifestyle,” advises Dr. Sullenberger. The American Heart Association strongly recommends eating a balanced diet, maintain reasonable body weight, stay at least moderately physically active (within your limits), and to check your cholesterol level regularly, especially if your family has a history of heart disease. Additionally, quitting smoking significantly reduces your risk of developing heart disease, heart attack, and stroke.

Prevention

The need for CABG surgeries is expected to expand by just over 5% in the seven years due to stress, obesity, sedentary lifestyle, and unhealthy habits. “For everyone [reading this] now, you never want to have to see a cardiologist or a cardiothoracic surgeon. The way you avoid that is doing everything you can to keep a healthy lifestyle,” advises Dr. Sullenberger. The American Heart Association strongly recommends eating a balanced diet, maintain reasonable body weight, stay at least moderately physically active (within your limits), and to check your cholesterol level regularly, especially if your family has a history of heart disease. Additionally, quitting smoking significantly reduces your risk of developing heart disease, heart attack, and stroke.

Written by: Michael Arce, Media Specialist
Any medical information published on this website is not intended as a substitute for informed medical advice and you should not take any action before consulting with a healthcare professional.