Coronary Artery Bypass Graft- aka CABG, Open Heart Surgery
What is it?
The CABG is a procedure during which one or more arteries that have been blocked are bypassed using a blood vessel graft in order to restore the normal blood flow to a patient’s heart. The grafts will generally come from the veins and arteries of the patient and are located in the arm, chest, or leg.
Once the general anaesthesia has been administered to the patient, the surgeon will remove the veins or prepare the arteries that will be used for grafting. If one of the veins that is used for the grafting is the saphenous vein, there will be a series of incisions made in the calf or thigh of the patient. If the vein that is being used is the radial vein, the same type of incisions will be made in the forearm. It should be noted that when arteries or veins are removed for grafting, it will not deprive the area that they came from of blood flow that is adequate.
It’s common for a part of the internal mammary artery to be used for the graft, in which case the incisions will be made in the wall of the chest. These arteries are used due to the fact that they show really great results for the long term. Due to the fact that they have a oxygen-rich blood supply of their own, the internal mammary arteries are often able to be kept intact and then attached to a coronary artery below the area that is blocked.
During the procedure, the patient’s chest will be opened so that the heart is visible and a heart-lung machine will take over the functioning of the heart while the procedure is being done. The chosen vein or artery is removed or disconnected and used to bypass the blockage in the heart.
There are some patients who may be eligible to have a minimally invasive surgery, which means that they won’t need to be put on the heart-lung machine. When this is the case, the surgeon will make smaller incisions for the graft and in the chest. This will present a decreased risk for infection and a faster recovery. During this type of surgery, the surgeon will employ advanced equipment in order to stabilize certain parts of the heart while bypassing the artery which is blocked. The heart continues to beat and circulate blood through the patient’s body.
Once the grafts are ready, the surgeon will make a small opening below the blocked part of the patient’s coronary artery that is diseased. Blood will then be redirected through this small opening once the prepared graft is put in place. If the vein is used from a leg or an arm, one end will be connected to the artery and the other will be connected to the aorta. If the vein that is used is a mammary artery, the one end will be connected to a coronary artery, while the other is still attached to the aorta. The procedure will be repeated on as many arteries as is needed. On an average, there will be three out of four coronary arteries that will need to be bypassed. Once the grafts are in place, the blood flow will be checked to be certain that the graft is supplying an adequate supply of blood to the patient’s heart. If it’s an on-pump procedure, the surgeon will use electric shocks to get the heart started again once the grafts are done. The heart-lung machine will be turned off, and the body temperature of the patient will return to normal with the help of the blood flowing again. The surgeon will then implant a pacing wire and insert a chest tube to help with drainage and close the chest cavity. Sometimes the surgeon will insert a temporary pacemaker to regulate the beating of the heart until the condition of the patient improves. Once the surgery is over, the patient will be transferred to ICU to be monitored closely.
Alternatives to Surgery
Once a blockage has been found in a person’s artery, there aren’t a lot of alternatives that they can choose other than removing it.
Before the Surgery
As this is a surgery that is very serious, there are quite few tests that are done to make sure that the patient requires the surgery. Some of the tests are EKG, stress test, cardiac catheterization, CT, chest x-ray, echocardiography, and blood tests.
Before the surgery is done, the patient needs to quit smoking and using other tobacco products. If it’s at all possible, the surgery should not be done until two to three months after the patient has a heart attack. It’s important for the patient to be stable medically before the surgery is done, if it’s possible. The patient will be told what they should expect during their surgery and following recovery period.
It is normal for the patient to meet with the anesthesiologist, the cardiologist, nurse clinicians, and the surgeon during an appointment or prior to the procedure. If the patient has a fever, sore throat, or cold a few days before the surgery is scheduled, it’s important for them to let the surgeon know.
The night before they go into surgery, the patient will shower with an antiseptic soap that the surgeon’s office will provide. The patient should not drink or eat anything after midnight. The day of the surgery, the patient will be admitted and they should have a list of all their allergies, records, and medications with them.
Prior to the surgery, the patient will be given heparin or another blood thinning medication that will help to prevent blood clots. The patient will be given a sedative, and the chest area and the area where the graft will be removed are shaved.
The length of the surgery will depend on how many grafts need to be done, but it will take anywhere from three to five hours, and can take longer than that if complications arise.
After the Operation - In the Hospital
The patient will wake up in the ICU of the hospital and will remain there for one to two days following the surgery. The patient is going to be connected to breathing and chest tubes, a ventilator, a monitor for their heart, and other types of monitoring equipment. A urinary catheter drains urine from the patient’s bladder. The ventilator and breathing tube are normally removed approximately six hours after the surgery is completed. The other tubes, however, will normally stay in place while the patient is in ICU.
The patient will be given medication to prevent their blood from clotting and to help with pain. A daily dose of aspirin will be started between six and twenty four hours after the operation.
The patient will start chest physiotherapy once the breathing tubes and ventilator are removed. The therapy will include frequent turning, taking deep breaths, and coughing. The patient may be given a mask which delivers oxygen in order to help with the loosening and clearing of lung secretions. There will be other exercises that the patient will be encouraged to do so that the circulation of the patient will be improved and to lessen the chance of complications that are associated with prolonged confinement to bed.
Barring complications, the patient can start resuming a normal routine on the second day after surgery. This will include sitting up, walking around a bit, and eating normal food. Before the patient is discharged, he or she will normally spend several days in a nonsurgical unit. While they are there, they are usually counselled about what they should eat and about the right type of exercise so that their heart stays healthy.
After this type of surgery, a patient will remain in the hospital from five to seven days.
After the surgery - At home
Once the patient goes home, they will be instructed on how to care for their wound and what types of changes that they should make to their lifestyle. This usually includes a diet and exercise program.
As this is a serious operation, there are quite a few complications that are associated with it, including:
Graft blockage or closure
Blocks developing in another artery or arteries
Development of atherosclerotic disease when saphenous are used
Abnormal rhythms in heart
Low or high blood pressure
Blood clots that lead to heart attack or stroke
Mood swings or depression
Memory loss or cognitive dysfunction
People who have the following conditions are more likely to have complications:
Recent heart attack
Congestive heart failure
A full and complete recovery from this type of surgery usually takes anywhere from two to three months and is gradual. The patient will feel weak and get stronger as time passes.
Estimated Costs for CABG Surgery