Heart bypass surgery

The build-up of fatty plaques and scar tissue within a segment of coronary artery can reduce the blood supply to the heart. A heart bypass operation is performed to bypass the narrowed segment, creating a new channel for blood to reach the heart. This is usually done by inserting a section of the patient’s saphenous vein, taken from the thigh or lower leg. Sometimes the internal mammary artery (from the chest wall) is used instead.

Other names for this operation include coronary artery bypass graft surgery (CABG) and coronary revascularisation.

Coronary heart disease#

Coronary heart disease is a narrowing of the arteries that supply blood to the heart. Fatty deposits rich in cholesterol stick to the artery walls, forming thickened patches called plaques (atherosclerosis). These plaques narrow the arteries and reduce the flow of blood to the heart muscle. A clot (thrombosis) may then form, blocking the artery and causing a heart attack.

The risk factors are mainly lifestyle related, and include:

• A diet high in saturated fats
• Cigarette smoking
• Obesity
• Lack of physical activity
• Uncontrolled diabetes
• High blood pressure
• A family history of heart disease

Preparing for surgery#

Once you and your doctor have decided that you will have a heart bypass operation, your doctor will discuss the risks in detail. This will include the type of anaesthetic you will have and the immediate post-operative care you can expect.

You will also need to discuss your medical history, allergies and current medications. Once in hospital, your vital signs, such as blood pressure and heart rate, are recorded, and you will have various investigations before surgery, including blood tests, x-rays and an electrocardiogram (ECG).

Your chest, arms and legs are shaved and your skin is washed with antiseptic solution. It is important not to eat or drink for some time before the operation. You may be given a pre-medication injection to make you feel drowsy and to dry up internal secretions.

The heart bypass operation#

Heart bypass surgery is performed under general anaesthetic. The saphenous vein (from your leg), the internal mammary artery (from your chest wall) or the radial artery (from your wrist) can be used as grafts. Commonly, between two and four coronary arteries are grafted, depending on the location and severity of the blockages.

The surgeon reaches your heart using one of two incisions: either down the length of your breastbone (median sternotomy) or beneath the left nipple (thoracotomy).

A heart-lung machine maintains your blood circulation while your heart is deliberately stopped. The vein or artery is then grafted onto the coronary artery so that blood can bypass the blockage. Sometimes the operation is performed while the heart is still beating (this is called beating heart or off-pump surgery).

Immediately after surgery#

You should tell the medical staff about any fears or anxieties in the days immediately after the operation, as emotional stress can place demands on your heart.

After the operation:

• You spend a day or two in the intensive care unit, with monitors attached to you near your bed.
• You have intravenous lines to keep your body fluids and electrolyte levels in balance.
• The medical and nursing staff watch your heart tracings closely and treat any irregularities that arise.
• You have a nasogastric tube (passed through your nose into your stomach) to drain excess stomach fluids, and a tube into your bladder to drain and measure your urine output.

Before you leave hospital:

• You are shown how to care for your wounds. Often, washing with soap and water is enough.
• You are given advice on angina (chest pain), including how to treat it and when to get medical help.
• Your doctor advises when you can return to work, resume driving and exercise strenuously.
• A physiotherapist shows you breathing and other exercises.
• Your doctor should give guidelines about restarting sexual activity, including positions that reduce exertion and what to do if you experience angina.

Complications of heart bypass surgery#

Some possible complications include:

• Stroke
• Haemorrhage
• Infection of the wound
• Heartbeat irregularities (arrhythmia)
• Kidney failure
• Fluid build-up around the lungs (pleural effusion)
• Blood clots in the leg veins (thrombosis)
• Thinking difficulties, such as reduced concentration and a shortened attention span

Taking care of yourself at home#

Be guided by your doctor, but general suggestions include:

• Take all prescribed medications strictly as directed by your doctor.
• Expect some discomfort around your wound site during activities such as sneezing or coughing. This is normal and nothing to be alarmed about.
• Watch for possible complications. Symptoms of wound infection may include redness, drainage of pus, heat or increasing pain at the wound site. Difficulty breathing or a swollen and tender calf muscle may also indicate a problem.
• Wear an elastic support stocking on the leg from which the vein was removed, and raise that leg regularly to reduce swelling.
• Avoid lifting, pulling or pushing heavy objects for at least six to eight weeks, as your breastbone needs at least three months to heal properly.
• Follow your doctor’s recommendations on diet and exercise. Eat a wide variety of fresh fruit and vegetables, wholegrain cereals and oily fish (such as salmon, tuna, sardines and mackerel), and avoid saturated fats found in animal products (including dairy foods) and hidden fats in pastries, biscuits, fried foods, snack foods, chocolate and cocoa.
• Don’t smoke.

Long-term outlook#

Your wellbeing in the long term depends on your commitment to healthier lifestyle changes. For example, if you continue to smoke and eat a high-fat diet, your bypass graft may eventually become clogged with fatty plaques. You will need to consult your health professionals (including your doctor and surgeon) regularly to ensure proper cardiac rehabilitation.

Some common experiences in the weeks and months after heart surgery include:

• Constipation, caused by medications, inactivity and the impact of surgery on the body
• Excessive sweating, particularly at night
• Emotional problems, including stress, depression and reduced self-esteem

Most people are free of angina after surgery and have a lower risk of heart attack, and they are usually able to lead a more active life.

Other forms of treatment#

The main alternatives to heart bypass surgery include:

• Drug therapy. The aim is to increase blood flow through your arteries and discourage further deposits of fatty substances. Along with medication, your doctor will usually ask you to lose weight (if overweight), stop smoking, modify your diet and follow an exercise plan.
• Balloon angioplasty. A cardiac catheter is passed into the narrowed section of the coronary artery and inflated. This stretches the artery and improves blood flow. A small mesh tube (stent) may then be inserted to keep the artery open.

Key points#

• Heart bypass surgery creates a new channel for blood to reach the heart, bypassing a narrowed segment of coronary artery
• The risk factors for coronary heart disease are mainly lifestyle related, including a high-saturated-fat diet, smoking, obesity, inactivity, uncontrolled diabetes and high blood pressure
• During surgery, a heart-lung machine maintains your circulation while the heart is deliberately stopped, and between two and four arteries are commonly grafted
• Long-term wellbeing depends on healthier lifestyle changes and ongoing cardiac rehabilitation
• Alternatives to surgery include drug therapy and balloon angioplasty

Where to get help#