Coronary artery bypass surgery

Overview

Coronary artery bypass grafting (CABG) is a surgical procedure that restores blood flow to parts of your heart that aren’t receiving enough. This operation can improve your heart function and how you feel, especially if you’ve recently had a heart attack or are at high risk of having one in the near future. This procedure is also known as coronary artery bypass graft surgery, coronary artery bypass surgery, or heart bypass surgery.

The heart condition that led to the blockage, such as atherosclerosis or coronary artery disease, is not treated by coronary artery bypass surgery. However, it can lessen symptoms like shortness of breath and chest pain. The procedure, referred to as CABG, may lower the chance of mortality from heart disease.

Reason for undergoing the procedure

Your heart relies on a continuous supply of blood to function properly, and this vital blood supply is facilitated by a network of arteries that encircle it. Ischemia occurs when certain tissues in your body, including those in the heart, do not receive sufficient blood flow.

Ischemia can inflict significant harm on the muscle cells within your heart, and in severe cases, these heart muscle cells may start to undergo cell death. To address ischemia, a surgical procedure known as Coronary Artery Bypass Grafting (CABG), often colloquially referred to as “cabbage,” is employed. This procedure is designed to restore proper blood flow to the damaged heart muscle.

Conditions treated

Coronary heart disease, a collection of conditions that includes heart attack and coronary artery disease, is the most common cause of undergoing CABG. Angina pectoris, characterized by chest pain resulting from heart ischemia, and silent myocardial ischemia, a condition where heart ischemia occurs without any noticeable symptoms, are both considered forms of coronary heart disease.

Coronary heart disease is characterized by a narrowing of the arteries in your heart caused by a deposit of a fatty, wax-like residue known as plaque. As plaque accumulates on the inside of your heart’s arteries, they stiffen and narrow. When a region of plaque ruptures, blood clots can form and cause blockages in the arteries. Ischemia in sections of your heart is caused by these obstructions, which can lead to a heart attack.

Risks

Because CABG is a significant procedure, there are some risks and complications. While the majority of these dangers and problems are avoidable or manageable, it is nevertheless critical to be aware of them. Possible hazards include:

• Infections. Infection is a possible surgical consequence. When infections spread throughout your body, they can induce sepsis, a potentially fatal immune system overreaction. Sepsis is a medical emergency, and having two or more of its symptoms (rapid heart rate, fever, chills, rapid breathing, or confusion) is as deadly as having a heart attack or stroke. Fortunately, due to improved surgical care and methods, severe infections after CABG are not common.
• Bleeding. Any major procedure carries this risk. To avoid this, patients who use blood thinners must discontinue them (under the supervision and guidance of their doctor) before to surgery.
• Arrhythmias. Atrial fibrillation, which increases the risk of stroke, is the most prevalent arrhythmia or irregular heart rhythm after CABG. Fortunately, it is usually only a short-term issue.
• Confusion or delirium. These induce symptoms such as agitation, difficulty thinking clearly, memory issues, or someone acting oddly (as if they are a different person).
• Other medical condition such as stroke, heart attack, or kidney issues.

Before the procedure

CABG is serious surgery, and patients must first go through a series of testing and other preparations.

Diagnostic imaging and laboratory examinations

Prior to undergoing CABG, a comprehensive series of tests is typically conducted to assess the procedure’s safety and necessity for the individual.

The following are examples of prospective tests, however they are not exhaustive:

• Laboratory tests that examine your cholesterol, blood sugar, complete blood count and other variables. Urine tests that examine how effectively your kidneys operate are among the additional tests that could be performed.
• Electrocardiogram (ECG or EKG)
• Echocardiogram
• Exercise stress test
• Nuclear cardiac stress test
• Coronary calcium scan
• Cardiac catheterization
• X-ray angiography or Computed Tomography (CT) scan angiography

Information and education

Preparing for CABG entails informing and educating you on what to expect and what you need to do before and after surgery to get the best possible outcome. You will learn about the following topics:

• Medications. Before the procedure, your doctor will go over the medications you’re taking. They will also advise you on which medications to continue taking and which to discontinue (and when to discontinue them). In some situations, they may change your prescriptions or start you on new ones.
• Surgical preparation. Your doctor will give you instructions and materials to help you prepare for the surgery. This includes knowing what kind of assistance you’ll require at home, what you can and cannot consume following the surgery, what essentials you’ll require at home, and more. It also contains instructions on how to bathe and groom yourself prior to the surgery.
• Expectation after surgery. Your doctor will also provide you with information and tools outlining what to expect during your recuperation. This includes how long it will take you to heal, how you will feel, signs to look out for, and other information.

During the procedure

CABG is a complex procedure that typically spans several hours, with the exact duration varying based on factors such as the type of CABG surgery, the number of bypasses needed, and other considerations. Most CABG procedures involve the following stages:

Anesthesia and life support

The initial stage in this surgery, as with other major surgeries, is to put you into a deep slumber. This prevents you from feeling discomfort during the procedure. It also helps you relax for the next steps in the preparation.

Because CABG involves heart surgery, different methods of life support are frequently used. These are some examples:

• Intravenous lines. Intravenous (IV) lines are tubes that allow doctors to directly inject drugs and fluids into your veins.
• Intubation and ventilation. Intubation is a procedure in which a tube is inserted down your neck and into your windpipe. They then connect that line to a machine known as a ventilator, which does your breathing for you. Your lungs continue to process and transmit oxygen into and carbon dioxide out of your bloodstream, but the ventilator moves the air.
• Urinary catheter. Before beginning surgery, doctors will put a tiny tube through your urethra and into your bladder. A catheter is a tube that permits urine to drain through it and into a bag. This allows you to “pee” unknowingly even when under anesthesia.
• Heart-lung bypass. This machine replaces your heart and lungs by pumping blood from your body into this machine, which also supplies oxygen and eliminates carbon dioxide from your blood. The blood is then pumped back into your body via an IV line by the machine. Using this equipment, clinicians can temporarily stop your heart, making some surgical procedures easier. A heart-lung bypass machine isn’t usually required during CABG, but it’s commonly used.

Blood vessel harvesting

CABG, or Coronary Artery Bypass Grafting, is the procedure aimed at creating a bypass for blood to reach blocked areas of the heart. These bypasses serve as detours, allowing blood to bypass the blockage. The process involves extracting a blood vessel from another part of your body, such as the leg, arm, or chest, and redirecting it around the obstruction. In cases where multiple arteries are obstructed, you may require two (double), three (triple), or even four (quadruple) bypasses, depending on the severity of the condition.

Surgery

During the CABG procedure, a cardiothoracic surgeon initiates by making an incision at the center of your chest to access your heart. They proceed by splitting your breastbone (sternum) down the middle and gently spreading and elevating your rib cage to gain full access to your heart.

Once they have reached the heart, the surgeon utilizes the harvested blood vessel to create the bypass. The upper end of this bypass is connected to your aorta, the large artery responsible for carrying blood away from your heart to the rest of your body. The lower end of the bypass is attached just past the blockage in the affected artery.

If necessary, the surgeon can restart your heart (if temporarily stopped) and restore blood flow after the bypass has been successfully established. Your rib cage is then carefully wired back into its original position to facilitate healing. Subsequently, the chest incision is closed using staples and stitches.

Different types of surgery

While CABG frequently employs the same techniques on the majority of patients, there are times when other approaches are preferable for your individual circumstances. There are several variations of this procedure:

• Off-pump CABG. This CABG procedure does not require the use of a heart-lung bypass machine. This implies that the surgeon does the entire procedure while your heart is still pumping, without stopping it. Not all patients are candidates for this kind of surgery, and it presents greater difficulties for the surgeon. However, some doctors have specialized education and expertise in carrying out CABG surgery in this manner.
• Minimally invasive CABG. The sternum and rib cage are not split or lifted during this particular CABG procedure. The surgeon instead reaches your heart through the spaces between some of your ribs using considerably tiny incisions. The off-pump approach may also be used in this type of the process.
• Robot-assisted CABG. A surgeon can use surgical robots, which are highly sophisticated equipment, to do CABG surgery. A surgeon “drives” the robot in order to accomplish this, controlling its motion. Robotic surgery doesn’t involve opening and lifting your sternum and instead makes tiny incisions. Robotic surgery may use the off-pump approach or heart-lung bypass.
• Hybrid procedure. In this process, CABG is combined with other methods or techniques. In most cases, at least one artery undergoes robot-assisted CABG, although the remaining unhealthy blood vessels are treated using non-CABG methods like stenting. A stent, a device with a frame-like structure, is inserted into an artery during stenting. Because the stent functions as a skeleton inside the artery, placing one helps keep the artery open.

After the procedure

Following surgery, CABG patients are taken to the hospital’s intensive care unit (ICU). Because ICU staff have specific training and experience that are better suited for persons with specialized needs like those who have just undergone CABG, staying in the ICU is required.

A patient can go to a standard medical-surgical room in the hospital for the remainder of their stay once they are stable and the doctor determines they are ready. Inpatient stays for CABG range from 8 to 12 days on average (they are greater for those who had a heart attack and shorter for those who had stable ischemic heart disease or other similar conditions).

Many CABG patients typically participate in a cardiac rehabilitation program before their discharge from the hospital. These programs, commonly known as cardiac rehab, play a crucial role in aiding recovery and enhancing strength following demanding cardiac procedures or events such as heart attacks. Cardiac rehab programs are staffed by a highly skilled team of professionals who have received specialized training. This team often includes nurses, exercise physiologists, nutritionists and dietitians, counselors and behavioral health experts, as well as doctors.

Outcome

After undergoing CABG, most patients will need several weeks to achieve full recovery. During this time, your healthcare provider will likely advise you to refrain from strenuous activities or situations that could put excessive stress on your heart and surgical incisions.

Your doctor is the most qualified individual to provide you with a precise timeline for your recuperation and inform you about what to anticipate. They will also guide you on when it’s safe to resume your regular activities, including work, exercise, driving, and more.