How do I prepare for bypass surgery?
In the weeks before surgery, you will be advised to stop smoking if you smoke. Tell your healthcare provider all the medications you are currently taking. If you take an anticoagulant, such as warfarin (Coumadin), aspirin, or clopidogrel (Plavix), you may be asked to stop or to reduce your dosage before the procedure. If you have diabetes, you should discuss your medications with your doctor for the day of surgery.
A few days before surgery, you will undergo a series of tests including an X-ray and an ECG, and your urine will be tested. You are not allowed to eat or drink after midnight the night before surgery.
What happens during the procedure?
The place where the healthy vein will be removed will be shaved if necessary and an antibacterial solution applied to both it and the chest. You will be given a sedative through an intravenous (IV) line. You may feel the needle prick when the IV line is inserted into your arm.
Throughout the procedure, you will be under general anesthesia; a breathing tube and machine will ensure you are breathing, and medicine in your IV will make sure you are asleep for the entire procedure. It will be constantly monitored by your anesthesiologist. A small catheter will monitor your heart function and pressure in the heart and lungs. A urinary catheter is also inserted in your bladder.
The blood vessels that are being used to bypass the blocked artery are first removed from their original location. If the saphenous vein in the leg is used, an incision is made from the ankle to the groin. If an artery in the chest is used, it can be accessed through the main bypass incision without making a separate incision. The surgeon makes an 11- to 12-inch incision in your chest and opens the breastbone to access your heart.
In traditional bypass surgery, your heart will be stopped for about 30 to 90 minutes and a heart-lung machine takes over the functions of the heart. Bypass surgery may also be performed off-pump where your heart remains beating (see Off-Pump Bypass Surgery).
The healthy blood vessel from the leg or chest is sewn into place to provide a detour around the blockage. It is referred to as the "graft." Once the blood is successfully flowing around the blockage, your heart is restarted and you will be taken off the heart lung machine. The breastbone is closed by wire, and the chest incision is closed with staples or stitches.
Bypass surgery can take from 3 to 6 hours, depending on how many blockages you have, and therefore how many arteries are being bypassed.
What happens after bypass surgery?
After surgery, you will be moved to a bed in the cardiac surgical intensive care unit. Your heart rate and blood pressure are continuously monitored for 12 to 24 hours; family can visit periodically. You will continue to get medications through an IV line.
Once you are awake and able to breathe on your own, the breathing tube will be removed. Your throat will feel dry and sore. You may feel groggy and disoriented, and the incision sites may hurt. Painkillers are given as necessary. On the first day, you will be fed through an IV line, but by the second and third days, you will be encouraged to sit up, walk a bit, and eat regular food. You may stay in the hospital for 4 days to a week or more; during this time, tests will be conducted to assess and monitor your condition.
See also: Physical Recovery
What does the MIDCAB procedure entail?
There are a few differences between the traditional bypass surgery procedure and the MIDCAB procedure. One is that an incision about 4 to 6 inches long will be made on the left side of the chest; through this incision, your surgeon will retrieve the healthy vessel to be used for the graft, though sometimes the saphenous vein from the leg will be used. As in traditional bypass surgery, if the saphenous vein in the leg is used, an incision is made from the knee or ankle to the groin.<
Instead of the breastbone being opened, various types of incisions are then made between or under the ribs so that the surgeon can reach different areas of the heart through these spaces.
MIDCAB can be performed on-pump, meaning with the use of a heart-lung machine, or off-pump. In on-pump MIDCAB, the heart will be stopped for about 30 to 90 minutes while a heart-lung machine takes over the functions of the heart. In off-pump surgery, special stabilizers, which are a bit like mini suction devices, are used so that the heart can still beat while the surgeon sews on the healthy blood vessel. The stabilizers restrict the heart's motion and create a stable and nearly still work area for the surgeon.
Once blood is flowing freely to the heart muscle, the chest incisions are stitched.
MIDCAB usually lasts an average of 2 hours.
You will stay in the ICU for about 24 hours after the procedure where normal breathing, circulation, and movement will be restored. Pain medication may be given, and if you feel up to eating, you are allowed to do so. The average hospital stay after MIDCAB is about 3 days.
What does the OPCAB procedure entail?
Except for the use of the heart-lung machine, the procedure is the same as that of traditional bypass surgery. Instead of the heart-lung machine, heart stabilizers and positioners, which are a bit like mini suction devices, are attached to the heart. The heart continues to beat, but the stabilizers keep the target area of the heart nearly motionless while the surgeon operates.
The entire procedure will take 2 to 5 hours, depending on how many arteries are blocked and how many grafts are needed.
References
1. American Heart Association. Heart Disease and Stroke Statistics - 2006 Update. Dallas, Texas: American Heart Association; 2006.
2. Ferguson TBJ, Hammill BG, Peterson ED, DeLong ER, Grover FL, STS National Database Committee. A decade of change -risk profiles and outcomes for isolated coronary artery bypass grafting procedures, 1990-1999: a report from the STS National Database Committee and the Duke Clinical Research Institute. Society of Thoracic Surgeons. Ann Thorac Surg. 2002;73:480-489.
3. Hussain KM, Kogan A, Estrada AQ, Kostandy G, Foschi A, Dadkhah S. Referral pattern and outcome in men and women undergoing coronary artery bypass surgery--a critical review. Angiology. 1998;49:243-250.
4. Jacobs AK, Kelsey SF, Brooks MM, et al. Better outcome for women compared with men undergoing coronary revascularization: a report from the bypass angioplasty revascularization investigation (BARI). Circulation. 1998;98:1279-1285.
5. Rahimtoola SH, Bennett AJ, Grunkemeir GL, Block P, Starr A. Survival at 15-18 years after coronary bypass surgery for angina in women. Circulation. 1993;88:II71-II78.
6. Herlitz J, Brandrup-Wognsen G, Karlson BW, et al. Mortality, risk indicators of death, mode of death an symptoms of angina pectoris during 5 years after coronary artery bypass grafting in men and women. J Intern Med. 2000;247:500-506.
7. Vaccarino V, Abramson JL, Veledar E, Weintraub WS. Sex differences in hospital mortality after coronary artery bypass surgery. Evidence for a higher mortality in younger women. Circulation. 2002;105:1176-1181.
8. Shevde K, Pagala M, Kashikar A, et al. Gender is an essential determinant of blood transfusion in patients undergoing coronary artery bypass graft procedure. J Clin Anesth. 2000;12:109-116.
9. Lindquist R, Dupuis G, Terrin ML, et al. Comparison of health-related quality-of-life outcomes of men and women after coronary artery bypass surgery through 1 year: findings from the POST CABG Biobehavioral Study. Am Heart J. 2003;146:1038-1044.
10. Vaccarino V, Lin ZQ, Kasl SV, et al. Gender differences in recovery after coronary artery bypass surgery. J Am Coll Cardiol. 2003;41:307-314.
11. Roach GW, Kanchuger M, Mora Mongano CM, et al. Adverse cerebral outcomes after coronary artery bypass graft surgery. N Engl J Med. 1996;355:1857-1863.
12. Newman MF, Kirchner JL, Phillips-Bute B, et al. Longitudinal assessment of neurocognitive function after coronary-artery bypass surgery. N Engl J Med. 2001;344:395-402.
13. Hogue CW, Barzilai B, Pieper KS, et al. Sex differences in neurological outcomes and mortality after cardiac surgery. A Society of Thoracic Surgery National Database Report. Circulation. 2001;103:2133-2137.
14. Stamou SC, Jablonski KA, Pfister AJ, et al. Stroke after conventional versus minimally invasive coronary artery bypass. Ann Thorac Surg. 2002;74:394-399.
15. Reinecke H, Roeder N, Schmid C, et al. Outcome of women is impaired in patients undergoing emergency coronary artery bypass grafting for failed PTCA. Z Kardiol. 2001;90:729-736.
16. Foster S, Mallik M. A comparative study of differences in the referral behaviour patterns of men and women who have experienced cardiac-related chest pain. Intensive Crit Care Nurs. 1998;14:192-202.
17. Seshadri N, Whitlow PL, Acharya N, Houghtaling P, Blackstone EH, Ellis SG. Emergency coronary artery bypass surgery in the contemporary percutaneous coronary intervention era. Circulation. 2002;106:2346-2350.
18. Davis KB, Chaitman BR, Ryan T, Bittner V, Kennedy JW. Comparison of 15-year survival for men and women after initial medical or surgical treatment for coronary artery disease: a CASS registry study. Coronary Artery Surgery Study. J Am Coll Cardiol. 1995;25:1010-1012.
19. The Bypass Angioplasty Revascularization Investigation (BARI) Investigators. Comparison of Coronary Bypass Surgery with Angioplasty in Patients with Multivessel Disease. N Engl J Med. 1996;335:217-225.
20. Society of Thoracic Surgeons Adult Cardiac Database. Personal Communication; 2003.
21. Brown PP, Mack MJ, Simon AW, et al. Outcomes experience with off-pump coronary artery bypass surgery in women. Ann Thorac Surg. 2002;74:2113-2120.
22. de Canniere D, Jansens JL, Goldschmidt-Clermont P, Barvais L, Decroly P, Stoupel E. Combination of minimally invasive coronary bypass and percutaneous transluminal coronary angioplasty in the treatment of double-vessel coronary disease: Two-year follow-up of a new hybrid procedure compared with "on-pump" double bypass grafting. Am Heart J. 2001;142:563-570.
23. Loop FD, Lytle BW, Cosgrove DM, et al. Influence of the internal-mammary-artery graft on 10-year survival and other cardiac events. N Engl J Med. 1986;314:1-6.
24. Dabal RJ, Goss JR, Maynard C, Aldea GS. The effect of left internal mammary artery utilization on short-term outcomes after coronary revascularization. Ann Thorac Surg. 2003;76:464-470.
25. Eritsland J, Arnesen H, Fjeld NB, Gronseth K, Abdelnoor M. Risk factors for graft occlusion after coronary artery bypass grafting. Scand J Thorac Cardiovasc Surg. 1995;29:63-69.
26. Peterson ED, Coombs LP, DeLong ER, Haan CK, Ferguson TB. Procedural volume as a marker of quality for CABG surgery. JAMA. 2004;291:195-201.
