INOVA HEALTH SYSTEM : TREATMENT OPTIONS : CORONARY ARTERY BYPASS SURGERY

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CORONARY ARTERY BYPASS SURGERY

What is coronary artery bypass surgery (also called CABG, CAB and bypass surgery)?

Coronary Artery Bypass Surgery is a surgical procedure offered at the Inova Heart Center. It is performed to relieve the signs and symptoms of coronary artery disease (resulting in angina or a heart attack).

Based on the extent of blockage in your coronary arteries, surgical treatment may be the best alternative. Bypass surgery creates new pathways of circulation around existing blockages or narrowings, allowing blood to reach your heart muscle again. In most cases, a healthy blood vessel from another part of your body (most commonly the saphenous vein in the leg, the internal mammary artery in the chest, and sometimes the radial artery in the arm) is used. This vessel becomes a "conduit" to the coronary artery at a point beyond the narrowed artery. The blocked or narrowed portion of the artery is "bypassed" with this vessel, allowing blood to flow to the heart muscle again.

Depending on the individual patient's condition, extent of coronary artery disease and coronary anatomy, one of four approaches will be chosen to perform the coronary artery bypass surgery. The operative approach is planned prior to surgery to meet the needs of each individual patient. Two of these approaches use traditional techniques and two use minimally invasive techniques.

The traditional or standard approach involves having a maximal incision that is called a median sternotomy, a midline chest incision over the length of the sternum (breastbone). The patient is placed on the heart-lung machine while creating the bypass grafts on the heart. .
The traditional or standard approach using "heart stabilizers" involves a median sternotomy incision. With this technique, the Inova cardiac surgeon uses heart stabilization techniques while creating the bypass grafts on a beating heart. The heart-lung machine is not used during this approach.
The minimally invasive approach using the heart-lung machine involves having a small incision on the chest wall to accommodate special instruments. The heart-lung machine is used while creating the bypass grafts on the heart.
The minimally invasive approach using "heart stabilizers" involves a small incision on the chest wall and stabilization techniques while creating the bypass grafts on a beating heart. The heart-lung machine is not used during this approach.

Click here for a day-by-day outline of what you can expect during your stay at the hospital.

What is a heart-lung machine?

Before the bypass grafts are sewn on, your heart may be stopped to allow the surgeon to suture on the surface of a still heart. During this time your blood will be circulated through a heart-lung machine. This machine performs the functions of the heart and lungs. The machine receives blood that is returning to the heart from all parts of the body, provides the blood with fresh oxygen from the oxygenator in the heart-lung machine (as the lungs would), then pumps blood back into the aorta (as the heart would), which distributes it throughout the body (except the heart and lungs). The heart and lungs are "bypassed" by this machine, thus allowing the Inova Heart Center surgeon to perform delicate maneuvers on a heart that is motionless and free from blood that ordinarily would interfere with his/her vision. During operations for valve disease and congenital heart disease, the heart is opened. The heart-lung machine is utilized so the surgeon can see the interior of the heart.

To prevent blood clots, or thrombosis, within the heart-lung machine circuit, the blood is first anticoagulated with a drug called heparin. Once use of the heart-lung machine is begun, the heart and entire body is cooled to lower its metabolic rate and oxygen consumption throughout the surgical procedure.

When the surgery is completed, the heart is rewarmed, which induces it to start beating again spontaneously. If it does not beat regularly, a low-voltage electrical shock is administered with paddles placed on the heart's surface.

What is cardioplegia?

When a patient is placed on the heart-lung machine, the heart and body are cooled to reduce the heart's metabolic requirements and oxygen consumption. Cold chemical agents such as potassium chloride can be infused into the heart to further reduce the metabolic requirements and oxygen consumption of the heart by quickly causing the heart to stop beating, causing cardioplegia (cardiac paralysis). Without these chemical agents, the heart will continue to quiver or remain in a state of ventricular fibrillation while the surgery takes place. This situation wastes energy resources in the heart that can be used when the heart needs to be stimulated to start beating again.

Cardioplegia, or cardiac paralysis, allows the surgeon to perform delicate procedures on a motionless heart. The chemical agents are reinfused into the heart periodically, in a solution of oxygenated blood. Thus, repeat infusions of blood cardioplegia solution provides oxygen to the heart while it remains at a standstill or arrest.

Once the surgery is complete, the cardioplegia agents are flushed out of the heart with warm, non-cardioplegic blood. The heart resumes contraction, and the heart-lung machine is discontinued. If the asystole is persistent, a temporary pacemaker can trigger the normal heart rhythm to resume. When any irregular heart rhythm is noted, appropriate actions are taken to correct the disturbance.

What is a coronary artery bypass conduit?

Coronary artery bypass graft surgery is the attachment (anastomosis) of conduits or grafts directly to the coronary artery at a point beyond the narrowed artery. A conduit is a new channel that conveys blood from a point where it is first attached at the aorta to a point below the narrowed artery in the heart. Several types of conduits are used for coronary artery bypass surgery at the Inova Heart Center. The saphenous vein, internal mammary artery and the radial artery are most commonly used conduits.

Saphenous vein conduits: A piece of vein from the inner aspect of your leg (saphenous vein) can be used for the bypass grafts. The vein will be removed from your leg. The initial incision may be made near the groin or near the ankle. The incision is then extended as far as necessary to expose a sufficient length of vein. Appropriate lengths of the vein are cut to be used as conduits. One end will be sewn onto the aorta, and the other end will be attached to the coronary artery below the blockage. The vein is connected so the valves inside the vein allow blood to pass through the vessel.
Internal mammary artery conduits: A blood vessel from your chest (the internal mammary artery) can be used for the bypass grafts. The upper end of the internal mammary artery is already attached to a branch of the aorta. The artery is dissected away from the soft tissue and muscle in the chest. Then, the lower end will be attached to the coronary artery below the blockage.
Radial (forearm) artery conduits: Although the saphenous vein and the internal mammary artery were the initial conduits utilized, the radial (forearm) artery can also be used as well, as an excellent conduit. Patients who are candidates for radial artery conduits are younger patients who have the presence of peripheral vascular disease, no saphenous vein (due to prior vein stripping, femoral popliteal bypass or bypass surgery), poor saphenous vein quality (due to varicose veins, or chronic leg swelling), or contraindications to bilateral internal mammary artery grafts (due to obesity, diabetes or lung disease).
Patients are not candidates for radial artery conduits for a variety of reasons. Some contraindications include patients with an inadequate back-up (ulnar) artery, Raynauds disease, prior arm trauma, renal failure, low pre-operative blood pressure, small radial arteries, and occupations that require fine dexterity.
An incision will be extended as far as necessary to expose a sufficient length of the vessel. The vessel will be removed from the arm. Appropriate lengths of the vessel will be cut to be used as conduits. One end will be sewn onto the aorta and the other end will be attached to the coronary artery below the blockage.
Patients who have a radial artery conduit will be given specific instructions on how to assess the extremity for circulation, sensation and movement as well as how to care for the incision and take an ulnar pulse.

What is endoscopic vein harvesting

The Inova Heart Center offers a significant advance in cardiac surgery-endoscopic vein harvesting. This is a new procedure that eliminates the long leg incision required to harvest the saphenous vein to construct a coronary artery bypass conduit. It is a videoscopic surgical technique that utilizes an endoscope and small incisions (1-2 inches in length) in one or both legs for insertion of the endoscopic surgical instruments to visualize the inside of the patient's leg on a television monitor. The saphenous vein can be visualized, then removed rapidly and less traumatically. This eliminates the traditional or "open" surgical procedure that requires a long leg incision (which may run the length of the leg) to harvest this leg vein for bypass surgery.

A portion of the post-operative pain associated with coronary artery bypass surgery is associated with the leg incision, not the chest incision. The endoscopic vein harvesting technique results in less tissue damage in the leg (as compared to the traditional surgical technique that requires a long leg incision). Thus, it offers a variety of benefits and facilitates recovery for patients. Benefits of endoscopic vein harvesting include fewer wound healing complications, less post-operative pain, accelerated ambulation and an improved cosmetic result (smaller incisions result in minimal scarring).

Since every operation is unique, endoscopic vein harvesting may not be appropriate for all patients. Your Inova Heart Center Surgeon will recommend which method is the best procedure for you.

Preparing for the surgical procedure

You will be asked to come into the hospital's Same Day Admission Program a day or two before surgery to have lab work, a chest x-ray film, an EKG and a physical examination. A nurse practitioner or physician assistant will discuss the risks of surgery and ask you to sign a consent form. They will also talk with you and your family about what you can expect while you're in the hospital. An anesthesiologist will talk with you about your medical history and will explain how medication will be given to keep you asleep and free of pain during your surgery. He/she will explain how you will awaken in the cardiovascular surgery intensive care unit.

Patients will also be asked to do the following: Stop taking aspirin or certain other medication 5 days before surgery, since they can cause excessive bleeding during surgery.
If you smoke, stop immediately.
Don't eat or drink anything after midnight the night before surgery.
Take a shower with a special soap the night before surgery to help prevent infection.

During the procedure

Each member of the heart surgery team plays a vital role in your care. The Inova Heart Surgeon and surgical assistants perform the surgery with support from specially trained nurses. The anesthesiologist monitors the delivery of anesthesia and makes sure you are asleep and free of pain. The perfusionist operates the heart-lung machine that keeps your blood circulating.

The surgery takes between 2 and 5 hours. You will be asleep during that time. First, to provide the cleanest area possible, the center of the chest, the groin area, and the inner aspect of one or both legs are shaved. Using the "traditional" approach (versus the minimally invasive technique) the Inova Cardiac Surgeon will make an incision down the middle of your chest (a medial sternotomy), separate the breastbone (sternum) and expose the heart. Another team member will prepare conduits from the leg.

You will be placed on the heart-lung machine. The conduits will be placed after the surgeon identifies the arteries to be bypassed. He will compare anatomic findings with cardiac catheterization films that are reviewed prior to surgery.

Once the surgical repair is completed, the heart and body are re-warmed, and the heart is stimulated to contract in a regular manner. The heart-lung machine will be discontinued, and the heart and lungs will take over their normal functions.

After a stable rhythm resumes, the surgeon assesses the anastomoses and the bypass grafts for hemostasis (control bleeding and stability of the repair). Temporary pacing wires are placed on the heart. These wires can be used if the heart rate becomes too slow (bradycardia) after surgery. They would be attached to a temporary, external pacemaker and the heart can be paced to a faster heart rhythm, thus maintaining an adequate blood pressure and perfusion to the new bypass grafts, if needed. Chest tubes are also placed in the heart (pericardial) sac and in the lung or pleural sac if an internal mammary artery was used, to drain retained blood or fluid.

After the surgery is complete, the cardiac surgeon once again reconfirms that all vital signs and the heart rhythm are stable. The drainage from the chest tubes is evaluated for bleeding tendencies. Then, the breastbone is rejoined with stainless steel wires and the skin edges sewn back together. The breastbone will take approximately six weeks to heal.

What is coronary artery bypass surgery (also called CABG, CAB and bypass surgery)?

The traditional or standard approach involves having a maximal incision that is called a median sternotomy, a midline chest incision over the length of the sternum (breastbone). The patient is placed on the heart-lung machine while creating the bypass grafts on the heart. .
The traditional or standard approach using "heart stabilizers" involves a median sternotomy incision. With this technique, the Inova cardiac surgeon uses heart stabilization techniques while creating the bypass grafts on a beating heart. The heart-lung machine is not used during this approach.
The minimally invasive approach using the heart-lung machine involves having a small incision on the chest wall to accommodate special instruments. The heart-lung machine is used while creating the bypass grafts on the heart.
The minimally invasive approach using "heart stabilizers" involves a small incision on the chest wall and stabilization techniques while creating the bypass grafts on a beating heart. The heart-lung machine is not used during this approach.

Click here for a day-by-day outline of what you can expect during your stay at the hospital.

What is a heart-lung machine?

What is cardioplegia?

What is a coronary artery bypass conduit?

Saphenous vein conduits: A piece of vein from the inner aspect of your leg (saphenous vein) can be used for the bypass grafts. The vein will be removed from your leg. The initial incision may be made near the groin or near the ankle. The incision is then extended as far as necessary to expose a sufficient length of vein. Appropriate lengths of the vein are cut to be used as conduits. One end will be sewn onto the aorta, and the other end will be attached to the coronary artery below the blockage. The vein is connected so the valves inside the vein allow blood to pass through the vessel.

Internal mammary artery conduits: A blood vessel from your chest (the internal mammary artery) can be used for the bypass grafts. The upper end of the internal mammary artery is already attached to a branch of the aorta. The artery is dissected away from the soft tissue and muscle in the chest. Then, the lower end will be attached to the coronary artery below the blockage.

Radial (forearm) artery conduits: Although the saphenous vein and the internal mammary artery were the initial conduits utilized, the radial (forearm) artery can also be used as well, as an excellent conduit. Patients who are candidates for radial artery conduits are younger patients who have the presence of peripheral vascular disease, no saphenous vein (due to prior vein stripping, femoral popliteal bypass or bypass surgery), poor saphenous vein quality (due to varicose veins, or chronic leg swelling), or contraindications to bilateral internal mammary artery grafts (due to obesity, diabetes or lung disease).

Patients are not candidates for radial artery conduits for a variety of reasons. Some contraindications include patients with an inadequate back-up (ulnar) artery, Raynauds disease, prior arm trauma, renal failure, low pre-operative blood pressure, small radial arteries, and occupations that require fine dexterity.

An incision will be extended as far as necessary to expose a sufficient length of the vessel. The vessel will be removed from the arm. Appropriate lengths of the vessel will be cut to be used as conduits. One end will be sewn onto the aorta and the other end will be attached to the coronary artery below the blockage.

Patients who have a radial artery conduit will be given specific instructions on how to assess the extremity for circulation, sensation and movement as well as how to care for the incision and take an ulnar pulse.

What is endoscopic vein harvesting?

Since every operation is unique, endoscopic vein harvesting may not be appropriate for all patients. Your Inova Heart Center Surgeon will recommend which method is the best procedure for you.

Preparing for the surgical procedure

Patients will also be asked to do the following:

Stop taking aspirin or certain other medication 5 days before surgery, since they can cause excessive bleeding during surgery.
If you smoke, stop immediately.
Don't eat or drink anything after midnight the night before surgery.
Take a shower with a special soap the night before surgery to help prevent infection.

During the procedure

After the procedure

Immediately after surgery, you will go to the Intensive Care Unit (ICU) where you will be constantly monitored. You will stay in the ICU for approximately 8 to 24 hours. The primary goals of care during this time are to maintain stable vital signs and to avoid any possible complication.

Right after surgery, you will breath through a tube in your throat connected to a breathing machine or respirator. The chest tubes will collect blood and drainage from your chest, the pacemaker wires will remain in place, and a catheter will be in your bladder to collect urine. A heart monitor will record your heart rate and rhythm. Intravenous (IV) lines will give you fluids and medications. All of these tubes and lines will be removed when you no longer need them.

When you leave the ICU you will go to another unit of the hospital called Cardiac Telemetry, where you will be an active participant in your care under the guidance of the heart surgery team. It will be very important for you to be up and around as soon as possible. Most patients may sit on the side of the bed the evening after surgery and may sit in a chair the next morning. The nurse will assist you with your first walk the day after surgery. Taking deep breaths and coughing are also important for recovery and for prevention of pneumonia. You will be instructed how to use a breathing device called an incentive spirometer, which should be used every hour while you're awake. In addition, you may receive medication to control your pain so you are comfortable and can participate in your care.

Before you are ready to leave the hospital you will be given a film to take home and a packet of information about recovery at home. The packet will contain information about activity, diet, and what you can expect during the next few weeks. Your nurse will go over your medications before you leave the hospital. Since you will not be able to drive for a few weeks, you will need to arrange a ride home from the hospital.

Click on recovery for more information about recovery from bypass surgery.