Heart Bypass Surgery

A heart bypass surgery is a surgery which is done to create a new passage to improve the blood and oxygen flow to the heart. It is done in the blocked or narrowed segment of the coronary arteries (arteries which supply oxygen-rich blood to your heart), due to which there is impaired blood supply to the heart’s surface. It is also known as Coronary Artery Bypass Graft Surgery (CABG) and Coronary Revascularisation or bypass surgery. Heart bypass surgery is used to treat people who are suffering from coronary heart disease (CHD), also known as coronary artery disease. In this condition, a substance called plaque (a wax-like substance mainly made up of fat, calcium, and cholesterol and is found in the blood) starts accumulating inside the coronary arteries. With time, this plaque can rupture or harden.

Hardened plaque can cause the narrowing or blockage of the coronary arteries and thus, the flow of oxygen-rich blood to the heat will be reduced. It can cause chest pain and discomfort called angina. In severe cases, it can lead to a heart attack. And in cases where the plaque ruptures, it can cause the formation of a blood clot on its surface. If the blood clot is large in size, it can block the blood flow through the coronary arteries. This can also lead to a heart attack.

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Heart bypass surgery is done when there is blockage or narrowing of coronary arteries. It is done to improve the blood and oxygen flow to your heart. Although heart bypass surgery is not advised in all individuals having coronary heart disease. There are also other treatment options available, such as Angioplasty with stents (a procedure where a small balloon is threaded in the blocked blood vessel to open it wide and a small mesh tube called stent is placed to prevent its narrowing in the future) or medical therapy.

Medical therapy involves medications and lifestyle changes, which include dietary changes and exercises. In some cases, both treatments (angioplasty and medical therapy) can be given. Heart bypass surgery is advised in the following cases where benefits are more than the risks. It includes the following conditions: 

• Narrowing of the main left coronary artery.
• Blocking or narrowing of all the three coronary arteries leading to a reduced amount of blood flow to the heart.
• Chances of the success rate of heart bypass surgery are more than that of angioplasty with stents.
• Requirement of another surgery to repair damage to heart valve (flap-like structures that prevent backflow of the blood when it is pumped by the heart) due to heart valve disease.
• Diabetes along with two or more narrowed arteries.
• Reduced pumping efficiency of the heart (decreased ejection fraction).

Consult with your doctor about the best treatment possible. The success of any treatment largely depends on your age and health.

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Before undergoing this surgery, your doctor should discuss in detail about all the risks involved in the operation. It includes the choice of most suitable anaesthetic (body-numbing agents that make you sleep during the surgery) or the post-operative care you’ll need after the surgery. Various factors, which are considered before conducting the surgery are:

• Any previous episodes of heart or other diseases.
• Treatment of any heart diseases in the past.
• Past surgeries.
• Medications that you are currently on.
• History of allergy to any medications.
• Age.
• General health.
• Family history of any heart diseases.

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What should you expect before the surgery?

Before undergoing the surgery, your doctor will advise you to get various tests done such as an electrocardiogram (ECG), echocardiography, chest X-ray, cardiac catheterization and coronary angiography. You must follow all the instructions given by your doctor regarding the preparations for your surgery. These are:

• He/she may ask you to stop certain medications which can alter the blood clotting time. These include ibuprofen, naproxen, and other medicines.
• He/she may also instruct you about what eat or drink on the day of surgery.
• It is highly recommended that you do not smoke before the surgery.
• You will be asked to use a special medicated soap to be used before the surgery.
• Do not drink or eat anything on the night before your surgery.
• In case you feel dryness in your mouth, rinse your mouth with water but don’t swallow it.
• Take the medicines as prescribed by your doctor but only with a little amount of water.

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Heart bypass surgery requires an expert team, which consists of a cardiothoracic or heart surgeon, anesthesiologist (a doctor who specialises in numbing the body for surgeries), perfusionist (heart-lung bypass machine specialist), some other surgeons and nurses.

Heart bypass operation 

Traditional coronary artery bypass grafting 

It is the most commonly performed coronary artery bypass grafting (CABG). It is done in the cases in which there is a need to bypass at least one major artery. This surgery is done on a still (non-working) heart. The steps of this procedure are discussed below:

• The chest bone is opened to gain access to the area near the heart and medications are given to stop the heart temporarily from beating.
• In order to continue the supply of oxygen and blood to the rest of the body, a heart-lung bypass machine is needed.
• After the surgery, the blood flow is restored and the heart starts beating on its own and in cases where the heart doesn’t restore its function on its own, mild electric shocks are required.
• Your body will be shaved and washed with an antiseptic solution in the area where the surgery will be performed.
• You will be given medication to induce drowsiness or sleepiness to conduct a painless surgery. You will be under general anaesthesia (medications to make you sleep and be pain-free during surgery).
• The anaesthesiologist will keep a check on all the vital signs, such as blood pressure, heart rate, and oxygen levels.
• The surgeon will gain access to your heart with the help of two possible incisions: an incision along the length of your breast bone (median sternotomy) or an incision right under the left nipple (thoracotomy).
• Medicines will be given to you to stop the functioning of your heart and also to protect it while it’s not working.
• Now the surgeon will take a vein or an artery from your body to use it as graft.
  • Artery graft
    The left internal mammary (breast) artery is the most common artery to be used as a graft. It is located in the chest wall. An artery from the arm (radial artery) can also be used. Artery grafts have lesser chances to get blocked over time.
  • Vein graft
    ​The saphenous vein is most commonly used as a vein graft. It a long vein located on the inner side of the leg. Vein grafts have higher chances of getting blocked with time. They are used more commonly as grafts as compared to arteries.
• These arteries/veins are then grafted to the narrowed segment of the coronary artery to bypass the blockage.
• After the grafting, the surgeon will restore the blood flow to your heart.
• The heart-lung bypass machine will be disconnected and your chest bone will be closed with the help of wires.

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Non-traditional Coronary Artery Bypass Graft

• Off-pump coronary artery bypass grafting 
  This surgery is similar to traditional CABG as here also, gaining access to the heart area involves opening the chest bone. However, in this surgery, the beating of the heart isn’t stopped and no heart-lung bypass machine is used. It is known as beating heart bypass grafting. 
• Minimally invasive direct coronary artery bypass grafting 
  It is similar to off-pump CABG as it is performed on a beating heart. However, rather than giving a single large incision, a number of small incisions are given between the ribs on the left side of the chest to open the chest bone. It is mainly done to bypass the blood vessels which are present in the front of the heart. It is an uncommon procedure as it is fairly new and not of much use in cases wherein two or more coronary arteries are needed to be bypassed.

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After the surgery, your doctor may recommend a to keep you for 1- 2 days in the Intensive Care Unit (ICU), where you will have:

• Continuous monitoring of your heart to ensure its normal activity.
• An intravenous line inserted in your arm for administration of medications and other fluids.
• A tube to help in breathing.
• A stomach tube to drain out secretions from your stomach.
• A catheter (a long tube inserted in the lower body) to drain off the urine.
• An arterial line to measure blood pressure
• Chest tubes to drain accumulated fluids from the chest, which usually happens after surgery.
• Oxygen therapy (through nasal prongs)
• Temporary pacemaker
• Bandages on the incision site

You will be shifted to a regular care room or ward within 24-48 hours of the procedure, where you have to stay for 3-5 days after surgery.

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There are a few risks associated with any type of surgeries, such as bleeding or infection on the surgical site. As with any kind of surgery, heart bypass surgery has risks too. The risks of this surgery increase with age or with the presence of any other medical conditions, such as diabetes, kidney diseases, lung diseases or peripheral arterial disease.

Possible risks that may arise during or after from heart bypass surgery include:

• Infection of the chest or wound infection 
• Fever
• Tiredness
• Chest pain
• Kidney problems
• Heart attack
• Heart rhythm problems
• Lung problems
• Depression and mood swings
• Stroke
• Memory loss, mental confusion
• Death

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Recovery at home will take about 6-12 weeks. Do follow the instructions, which are given by your doctor regarding:

• Care during healing of the incision.
• Recognizing any signs of infection and other complications.
• Situations when you need to call the doctor right away.
• Follow up appointments.

Other things that you should keep in mind are: 

• Don’t miss any prescribed medications.
• Don't be alarmed if certain forceful activities, such as coughing or sneezing cause discomfort.
• It may be there till you recover fully.
• Keep a check on any possible complications, such as redness, pus formation or pain in the surgical area.
• Avoid lifting, pulling or pushing heavy objects as it can delay the healing of the breastbone.
• Follow a healthy diet and light exercise routine as per your doctor’s advice.
• Eat fresh fruits and vegetables.
• Avoid foods containing saturated fats and hidden fats such as cakes, pastries, dairy products, pizzas, burgers and other such fast food.
• Avoid smoking.

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Just like any surgery, the recovery from this surgery also takes time. You will require at least 3-6 months to see the benefits of the surgery. In the majority of cases, the grafts work very well for years without any complications. Some people may experience a few common problems while recovering from the surgery, such as constipation, excessive sweating, emotional problems including stress or depression and reduced concentration or attention.

The prognosis or outcome of this surgery largely depends on your commitment to better and healthier lifestyle choices. It mainly includes:

• Taking a healthy diet.
• Regular physical exercise.
• Not smoking.
• Controlling your diabetes.
• Treating high blood pressure.
• Controlling your blood cholesterol level.

You will be able to lead an active and healthy life after the heart bypass surgery as it lowers the risk of heart attack or any other heart diseases.

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