Bypass Surgery: Common Questions

Why do you need bypass surgery?

If you are suffering chest pain or other symptoms that may indicate a cardiovascular problem, your doctor will likely want you to undergo an angiogram (cardiac catheterization) to see if your coronary arteries are blocked by plaque. A blockage can cause a decrease in the supply of blood and oxygen to the heart, and over time can lead to debilitating chest pain or a heart attack.

If angioplasty proves unsuccessful, the position of the blockage is too difficult to access by angioplasty, or you have severe blockages in multiple major vessels, your doctor may recommend that you undergo coronary artery bypass graft (CABG) surgery.

Bypass surgery has been performed for nearly 40 years. Cardiovascular surgeons have received extensive training on bypass techniques. More than 500,000 bypass procedures are performed each year in the United States, making it the most frequently performed major surgery in the country.

What happens during bypass surgery?

Bypass surgery is a major operation that usually lasts between two and six hours. Pre-operative medications are often administered by mouth, muscular or subcutaneous injection, or intravenously. You will receive general anesthesia and be completely asleep.

During bypass surgery, the chest bone is separated, and the ribs are spread apart to allow visible and physical access to the heart. In most instances, blood circulation and breathing functions will be taken over by a heart-lung machine. The cardiac surgeon uses a piece of vein or artery to form a bypass to enable blood to go around the blockage. Several blockages can be bypassed during surgery.

What is a graft?

A graft is a blood vessel that has been created to bypass a blocked artery. It is usually taken from the internal mammary artery in the chest, the saphenous veins from the leg, or in rare instances from the radial artery in the arm. The graft is attached above and below the area in the artery where there is a blockage, so that the blood can use the new, unblocked path to flow freely to the heart.

From stress tests, angiograms and intravascular ultrasounds, your doctor is able to determine exactly how much of the heart structure needs repair. Some patients undergo double, triple or even quadruple bypasses, based on their specific needs. The number of grafts is not as important as is the bypass of the necessary blockages.

Doctors have found that grafts are most successful when attached to major coronary arteries rather than smaller arterial branches. Doctors have also found better results for bypass surgery when there are discrete, localized blockages rather than a buildup of plaque throughout an artery.

Will my heart be stopped?

In some cases, your blood circulation and breathing functions will be carried out totally by a heart-lung machine during surgery, also known as cardiopulmonary bypass. However, more coronary artery bypass surgeries are being done while the heart is still beating (called the off-pump technique). The beating heart approach may reduce the risk of neurologic injury, stroke and other complications associated with the heart-lung machine, and leads to a shorter hospital stay for patients.

Are there any transfusions involved? Should I bank my own blood?

Ordinarily, as with any serious heart surgery, blood transfusions are necessary during bypass surgery. The blood used for your surgery will be matched by type and Rh factor, and provided by a local blood bank.

You may be familiar with the case of Arthur Ashe, a well-known tennis player and activist who ultimately died of AIDS-related pneumonia. He acquired the AIDS virus from a transfusion received during a bypass procedure performed in 1983. Although this result was devastating, the national blood banks have advanced a great deal in the past 20 years, and blood is screened much more carefully for contamination, including AIDS and other infectious diseases.

Unless your surgery is scheduled in less than 72 hours, and if your doctor gives you permission, arrangements can be made for banking your own blood for surgery. You also may have family or friends with a compatible blood type donate blood for your surgery. The hospital, the Red Cross or blood bank can provide family members and friends with necessary information about blood donation for your surgery.

Bypass procedures have been performed without transfusion. Some patients, such as Jehovah's Witnesses, are restricted from using another person's blood. Studies have shown that bypass procedures can be performed "bloodlessly," although these operations have had a higher rate of mortality.

What is minimally invasive bypass surgery?

Minimally invasive coronary artery bypass surgery (MIDCAB) involves a significantly smaller incision - only three inches - instead of splitting your sternum with a six- to eight-inch incision.

An artery that supplies blood to chest muscles is grafted to the left anterior descending artery (an important artery located close to the chest wall). Your heart continues to beat during the surgery, instead of being attached to a heart-lung machine. You may be given a drug to reduce your heartbeat.

Surgeons can also use a slightly different approach by making small incisions in your chest and viewing the surgery on video monitors. For this procedure, called port-access coronary bypass surgery, your heart is attached to a heart-lung machine.

Doctors are also exploring the use of robotics and telecommunications to perform minimally invasive surgeries, or to provide assistance to fellow surgeons, at remote locations.

The number of minimally invasive coronary bypass surgeries is rising, and now represents about 10 to 20 percent of all bypass operations performed annually. Compared to a traditional bypass surgery, minimally invasive bypass surgery is cheaper, shorter and less painful, requires fewer blood transfusions and reduces your recovery time. Hospital stays for MIDCAB patients can be three to four days, instead of five to six days for a traditional bypass.

However, this type of surgery is only for certain patients with one or two blocked arteries, and the long-term results have not been determined.

What are the risks?

The current success rate for bypass surgery is 95 to 98 percent, meaning that between 2 and 5 percent of all patients have complications, including death. The survival rate has improved over time.

As with any surgical procedure, there are risks of infection and heavy bleeding. There also are risks associated with anesthesia. These can include adverse reactions to medication and breathing problems. Postoperative pneumonia and wound infection also are common complications arising from open-heart surgery.

How successful is bypass surgery? Can I expect to live a long life?

Studies have shown in 80 to 95 percent of patients, bypasses made with segments of the mammary artery still performed efficiently 10 years after surgery. Two-thirds to 75 percent of patients who received grafts from leg veins still had satisfactorily unrestricted blood flow after 10 years.

Remember that even if your graft becomes blocked, you may not need additional bypass surgery. However, you may be a candidate for balloon angioplasty and insertion of a stent. (See Angioplasty: A Patient Guide)

Where will the surgery take place, and how can I prepare for it?

The surgery will be performed in a hospital operating room.

Some individuals are unaware of the extent to which their arteries are clogged until they have a heart attack. In cases such as these, a cardiologist or emergency room doctor will probably quickly determine whether bypass surgery can be successful. There might be little time to discuss options or extensively educate you or your family.

Ideally, you have discussed your health history with a cardiologist. You may have been treated with cholesterol lowering or blood pressure-lowering medications for some time. However, because of chest pain or test results from a stress test, it is evident to your doctor that bypass surgery is a necessary step. If you need additional input from your doctor, or perhaps a second opinion, it is in your best interest to get it as quickly as possible. In most cases, advanced coronary artery disease should be treated as soon as possible, to avoid further damage to the heart.

How long is the surgery?

Typically, traditional bypass surgery takes between two and six hours, depending on the number of bypasses to be performed. Minimally invasive bypass surgery usually takes two to three hours.

Will I be awake?

No. You will be under general anesthesia throughout the procedure.

Where will my family be?

Because the surgery must be performed in a sterile environment, family members are encouraged to remain close by in a hospital waiting room.

Where will I go directly after surgery?

Patients are typically observed for 24 to 36 hours in the cardiac intensive care unit (CICU). The CICU has limited visitation hours.

What is it like in the CICU? How will I feel after the surgery?

When you first wake up in the CICU, you will be groggy or slightly disoriented. This is normal. You will still have a tube in your mouth, connecting you to breathing monitors and apparatus. Until you are able to breathe on your own, you will have difficulty talking (because of the tube) and will be unable to eat.

There are numerous monitors and machines in the CICU; it is not as quiet or cozy as a normal hospital room. Nurses will be watching your vital signs (temperature, pulse, breathing) constantly to make sure that you are recovering as expected. You may initially find your hands strapped down so that you cannot disconnect any of the monitoring wires. Once your condition has stabilized (approximately 24 to 36 hours), you will be moved to a regular hospital room, where you can have more frequent visitors and rest more peacefully.

How long will I be in the hospital?

The overall hospital stay, including both the CICU and a regular hospital room, is generally between four and six days if you undergo a traditional bypass surgery. You could be in the hospital for less time - three to four days - following minimally invasive surgery.

Will I have a special rehabilitation program?

Your doctor will place you on a specialized postoperative rehabilitation and prevention program, which usually includes supervised exercise, dietary and lifestyle changes. You should be careful to protect the area around the leg or arm from which the vein was harvested. This may take a few months to return to normal.

Will I be in pain after the procedure?

You will receive medications in order to cope with the immediate surgical recovery. However, your doctor should talk to you about the difference between pain from the incision versus pain due to low blood supply to the heart muscle following surgery. If you have any questions about chest pain, contact your doctor. Even if you have had prior surgeries, be aware that bypass patients undergo a more painful recovery than do other surgery patients.

When can I walk?

You will be encouraged to walk before you leave the hospital.

When can I drive?

Patients are generally able to drive approximately three weeks after surgery. Driving is, in general limited by the comfort and stability of the scar to the chest rather than cardiac issues.

When can I resume sexual activity?

In most cases, sexual activity can be resumed approximately four weeks after surgery. Your doctor may give you an indicator, such as being able to climb two flights of stairs without stopping, before you resume sexual activity.

When will I be able to return to work?

Depending on the amount of physical exertion required for your job, you will likely be able to work within 12 weeks, and possibly even sooner.

When can I stop the medications that I was on before the surgery?

This will have to be discussed with your doctor. You will likely need several medications for a few months, and you will likely need to have your cholesterol controlled with statins. Bypass surgery does not cure the underlying problem that caused arteriosclerosis, but it does give you time to prevent further problems.

Sources

Minimally Invasive Heart Surgery. American Heart Association Web site, 2000.

Coronary Artery Disease Treatment - Surgery. Cleveland Clinic Heart Center Web site, April 2001.

Minimally Invasive Direct Coronary Artery Bypass, MIDCAB. Brown University Division of Biology and Medicine Web site.

Mack MJ, MD. Minimally Invasive and Robotic Surgery. Journal of the American Medical Association , February 2001:568-572.

Baumgartner WA, MD. What's New in Cardiac Surgery. Journal of the American College of Surgeons . March 2001:345-355.

Mayo Clinic Health Letter , May 1994.

Dr. David Allie, M.D., Cardiovascular Institute of the South;

HealthAnswers (Orbis-AHCN); Ask the Doctor, Infinity Heart Institute;

Virtual Hospital, Iowa CHAMPS;

Dean Santerre, Anatomy of the Human Heart;

Dr. Joseph Galichia, Heart Homepage.