Coronary Artery Bypass Graft Surgery - CABG
Coronary Artery Bypass Graft Surgery (CABG) surgery is performed to bypass clogged arteries supplying the heart.
Heart bypass surgery creates a detour or "bypass" around the blocked part of a coronary artery to restore the blood supply to the heart muscle. The surgery is commonly called coronary artery bypass graft, but also is referred to as CABG (pronounced "cabbage"), bypass surgery or coronary bypass.
After the patient is under general anesthesia and completely free from pain, the heart surgeon makes an incision in the middle of the chest and the breast bone is split to access the heart.
Through this incision, the surgeon can see the heart and aorta (the main blood vessel leading from the heart to the rest of the body). After surgery, the breastbone will be rejoined with permanent wires and the incision will be sewn closed.
Artery and vein grafts
If a vein from the leg, called the saphenous vein, is to be used for the bypass, an incision is made in the leg and the vein removed. The vein is located on the inside of the leg, running from the ankle to the groin. The saphenous vein normally does only about 10% of the work of circulating blood from the leg back to the heart. Therefore, it can be taken out without harming the patient or harming the leg.
It is common for the leg to swell slightly during recovery from the surgery. It may last up to 4 weeks after surgery and is treated by elevating the leg.
The internal mammary artery (IMA) is normally used as a graft. This has the advantage of staying open for many more years than the vein grafts, but there are some situations in which it cannot be used.
The left IMA, or LIMA, is an artery that runs next to the sternum on the inside of the chest wall. It can be disconnected from the chest wall without affecting the blood supply to the chest. It is commonly connected to the artery on the heart that supplies most of the muscle, the left anterior descending artery, or LAD.
Occasionally other arteries are used in bypass surgery. The most common of these is the radial artery. This is one of the two arteries that supply the hand with blood. It can usually be removed from the arm without any impairment of blood supply to the hand.
In the standard approach, the patient is connected to the heart-lung machine, or bypass pump, which adds oxygen to the blood and circulates blood to other parts of the body during the surgery. This is necessary because the heart muscle must be stopped before the graft can be done.
One end of the graft is stitched to an opening below the blockage in the coronary artery. If the grafted vessel is the saphenous vein or the radial artery, its other end is stitched to an opening made in the aorta. If the grafted vessel is the mammary artery, its other end is already connected to a larger artery.
The entire surgery can take 4-6 hours. After the surgery, the patient is taken to the Cardiac unit. For a few days after the surgery, the patient is connected to monitors and tubes.
Other surgical techniques for this procedure also are being used. One method is to avoid the use of the heart-lung machine. This is called off-pump coronary artery bypass or OPCAB. This operation allows the bypass to be created while the heart is still beating. This procedure has some benefits in selected groups of patients such as those with a history of stroke, renal failure and use of limited lung function.
Minimally Invasive Direct Coronary Bypass (MIDCAB)
In some cases in which blockages are more accessible, the surgeon can use an alternative approach called minimally invasive direct coronary artery bypass or MIDCAB, or MICS CABG. In contrast to open-heart bypass surgery in which the chest is cut open at the sternum to gain access to the heart, this technique allows for smaller incisions which avoid splitting the breastbone.
When considering the risks of CABG, it is important to remember that bypass surgery has been performed for more than 50 years. Cardiovascular surgeons have received extensive training in bypass techniques.
CABG is the most frequently performed major surgery in the United States, with over a half million procedures performed each year. As with any surgery, the health of the patient prior to surgery is a major consideration in determining risks.
- Age -- patients over 70 are at a slightly higher risk for complications
- Gender -- women have a slightly higher risk
- Previous heart surgery -- puts a person at a higher risk
- Having another serious medical condition (such as diabetes, peripheral vascular disease, kidney disease, or lung disease)
Possible risks in having CABG are:
- Internal bleeding which occurs in 1-4% of patients
- Heart attack, which occurs in 5% of these surgeries
- Stroke, which occurs in 1% of these surgeries (the risk is greatest in those over 70)
- Blood clots
- Death, which occurs in 1 - 2% of those who have the surgery.
Sternal wound infection, which occurs in 1 - 4% of these surgeries (this complication is most often associated with obesity, diabetes, or having had previous CABG)
- In about 30% of patients, "post-pericardiotomy syndrome" can occur anywhere from a few days to 6 months after surgery. The symptoms of this syndrome are fever and chest pain. It can be treated with medication.
- The incision in the chest or the graft site (if the graft was from the leg or arm) can be itchy, sore, numb, or bruised.
- Some people report memory loss and loss of mental clarity or "fuzzy thinking" following CABG.
- As with all surgeries, there is a risk for heavy bleeding. In some situations a transfusion is needed during or after surgery.
- There are general risks from anesthesia. These include reactions to medications and problems breathing.
Preparing for admission
Pre-anesthesia Clinc Visit (PAC)
You will have a pre-anesthesia clinic visit 1-5 days prior to your surgery, so pre-operative testing can be performed. These tests include but are not limited to:
- Blood and urine testing
- Chest X-ray
- other tests may be recommended
The respiratory therapist will teach you how to use your incentive spirometer, deep breathe and cough. An incentive spirometer is used to help expand you lungs therefore, you will see this again after your surgery.
During your PAC visit you will also receive instructions regarding when to arrive at the hospital, where to park, and where to check in.
- Do not eat or drink after midnight the previous evening.
- The night before and the morning of your surgery, you should have bathed with Chlorhexidine.
- Wear comfortable clothes that have an elastic waistband. You may feel bloated after surgery and should wear loose clothes at home.
- You may have been asked to stop taking your aspirin, blood thinner or anti-inflammatory medication 5-10 days prior to surgery.
- Do not wear any jewelry (this includes wedding rings)
- Remove finger and toenail polish
At the hospital
After getting admitted, you will go to the preoperative holding area. You will meet the anesthesiologist and operating room nurse there. After the interview, you will be offered a sedative medication and the anesthesiologist will place an IV. This enables us to infuse fluid if needed. You will have some of your body hair clipped from your chest and legs to decrease risk of developing an infection. You will also have a Foley catheter placed to drain your bladder. This allows the nurses to keep track of how much urine you are producing to make sure your kidneys tolerated the surgery well. The catheter is usually taken out 1-2 days after surgery.
During the surgery
Please advise family members that the surgery will take several hours. It varies from case-to-case, so an exact timeframe cannot be given. Throughout your surgery, a staff member will update your family on the progress of your procedure and the chaplain will be available to offer emotional and spiritual support to your family as needed.
After the surgery
You will be taken to the cardiac unit. You will stay there for 3-5 days. The average length of hospital stay is 4-5 days. You will probably not remember much of the first day postoperatively and will sleep intermittently. Nurses will be checking on you frequently, but you will usually fall right back to sleep due to anesthesia and pain medicine.
When you first wake up from surgery, it is very likely that you may still have a breathing tube in place and be assisted on a ventilator. You will be unable to speak while you have the breathing tube in. In approximately 2-4 hours, or as soon as your lungs are ready to breathe on their own, the nurse will remove the breathing tube.
It is important to try to keep your pain under control. Your nurse will ask you to “rate” your pain. “0” is no pain and “10” is the worst possible pain. Please try to keep your pain under 3. Notify your nurse when you are in pain so medication may be administered to you through your IV. You are not going to be pain-free after this surgery, but it will be easier to control your pain if you ask for your pain medication when the pain is starting to escalate and reaching the 4-5 area. The benefit of this is that it is easier to treat a pain level of 4-5 than a level of 9-10 and the benefit of pain medication will be felt a lot sooner.
The surgical procedure may cause you to accumulate excess fluid in the chest. Tubes are placed in the chest cavity and will come out of the chest just below the chest incision. These are called “chest tubes”. One tube drains any excess fluid that may accumulate in the chest. There may be a second and third tube to the right and left of the center tube. These are used to help keep the lungs inflated. These are usually removed 1-2 days after surgery. After you go home, there may be some clear/yellow drainage from the incisions. This is normal. Clean the site with soap and water and leave it open to air. If the site is still draining, you may cover it with a band-aid. Change the band-aid daily and as needed if saturated.
Temporary pacemaker wires
These may have been placed during your procedure and are attached to your heart. The wires may be connected to a box on the outside o f you body which allows your heart rate to be changed in needed. These wires are removed before you leave the hospital.
It is not uncommon to gain 5-10 pounds in fluid after surgery. This is due to fluid retention. When you undergo surgery, your body perceives the stress and in response, starts to store fluid. This is called the “fight or flight” response. Your body perceives the stress and in response, pushes fluid into the tissue to store. Your doctor may order Lasix or a diuretic, which pulls the fluid out of the tissue and into the bloodstream for your kidneys to filter. You are usually down to within 2-3 pounds of your pre-surgery weight when you go home. After you are home, please weigh yourself every day and record it on the form given to you. If you have more than a 5 pound weight gain in two days, call your doctor.
Swelling in the Legs
Also, it is not uncommon for your legs to swell, especially the leg that the veins were taken out of. Keep your legs elevated above your heart when you are not walking around. There also may be some bruising below or around the incision. This will go away in a week or two. Your physician will instruct you on the use of TED hose. TED hose are special compression stockings designed to help with healthy blood flow and guard against blood clots in the legs.
It is important to take deep breaths after surgery. Your normal tendency is to take short, shallow breaths because it hurts to take a deep breath. You will receive a heart-shaped pillow after surgery. Use this pillow to support your chest when you cough or move. You will be given an incentive spirometer that you were trained to use during your PAC visit prior to your surgery. You suck into this machine and try to expand your lungs as much as possible. This should be done approximately 10 times every hour. Do not do this rapidly or all in quick succession because you will get lightheaded. The reason you need to do the deep breathing is to expand your lungs. When you have the chest incision, you take short breaths and only expand 1/3 to 1/2 of your lung. When you do not expand the lungs completely, there is little air exchange in the bases. If your lungs sit there with little activity, they become a perfect environment for bacteria to grow and you may develop pneumonia. If you are watching television, a good way to remind yourself to breathe is to use your spirometer during every commercial break. You will be asked to continue this after you are discharged from the hospital.
Your activity level slowly increases and starts with sitting on the side of the bed and hanging your feet down. Next is usually sitting in a chair. The nurse will help you in to the chair. You will be asked to call the nurse when you get tired and not to cross you legs while you are sitting as it puts pressure on the veins in the legs and slows the blood flow. You will also want to keep your feet up when in the chair. Your activity will be increased to walking which is an important step in your recovery.
After surgery, you may feel your chest pounding, lightheaded, dizzy, weak, sweaty or pale. This could be from an irregular heart rhythm called “atrial fibrillation.” If you are in atrial fibrillation, check your pulse. You will usually have a pulse greater than 115-120 and the pulse is irregular. There is a chance of going into atrial fibrillation after surgery. This may happen the day after surgery, a week or a month later. If this happens and you are at home, call your cardiologist. This condition is not life-threatening, but the sooner you are treated, the better.
Please note, it is normal to have a higher resting heart rate after surgery. For example, if you had a resting heart rate of 80 before surgery, you may have a heart rate of 100-110 after surgery. This is due to your body responding to the stress of surgery and will return normal, but it may take 1-2 months.
Atrial fibrillation is treated with medication for about 4-6 weeks. Usually, your heart will convert back into a regular rhythm called “normal sinus rhythm.” Your cardiologist will determine if you can discontinue your medication if you are in a regular rhythm.
What to expect after you go home
Generally speaking, it takes 2-4 weeks before you start to feel like yourself again. What this means is that you will not have a lot of energy and you will become fatigued with minimal activity. This is normal. Heart surgery is a major surgery and it takes your body 2-4 weeks to cope with the stress and get back into a normal rhythm. The full benefits from the operation may not be determined until 3 - 6 months after surgery.
We recommend that you see your family physician the first week to ten days after surgery so they have baseline knowledge of what your incisions look like and how you are doing overall. The surgeon will see you in 2 weeks and the cardiologist usually sees you in 2-4 weeks.
Take your medicines as you have been instructed and only those listed on your discharge sheet. Use your pain medication as needed for activity and comfort.
Care of incisions
Shower and wash your incisions daily with a non-perfumed soap. Use fingertips instead of a washcloth. No tub bath or Jacuzzi until your wounds are healed. This time frame may vary from person to person as not everyone heals at the same rate. Pat your incisions dry. Do not use creams, lotions, Neosporin or vitamin E on your incisions until they are healed. Watch for any signs of infection such as redness, swelling, extreme tenderness, cloudy pus-like drainage or a separation of your incision. Women should wear a bra during the day and take it off at night. If the bra is too uncomfortable, you may use the breast binder given to you in the hospital.
Many patients have trouble moving their bowels after surgery for 1-2 weeks due to pain medicines. Moving around more, drinking plenty of water (if you are not a heart failure patient) and taking an occasional laxative as needed can help. You may also have a stool softener ordered by your doctor.
During this time, you may not have an appetite and most food has no taste. We recommend eating 6-8 small meals per day rather than 3 large meals. Things that may seem appealing are cooler, lighter foods. For example: Jell-O, sherbet, ice cream, fruit and salads. Eat what sounds good. After you get your appetite back, then modify to a low fat, low cholesterol diet. Please try to avoid salt. Your body’s natural response to the surgery is to retain fluid and a high salt intake will contribute to fluid retention. You may cook with salt, but try not to add any salt when eating. If you feel you need the nutrition, you may use Ensure or Boost supplement drinks. If you are diabetic, Carnation instant breakfast has a sugar-free supplement drink.
Most people generally do not sleep well after surgery. If you sleep 2-3 hours at a time, you are doing well. This is part of a normal recovery. Your sleep pattern will return to normal as your body recovers
We ask that you monitor your temperature twice a day and record it on the form given to you at the time of discharge from the hospital. If you have a temperature greater than 101°F, call your physician.
How you may feel
People sometimes are depressed after their surgery for many reasons. It may be due to the anesthesia lack of sleep slow recovery or medicines. Helpful ways to get over these feelings include being active in your recovery program, taking to your doctor, nurse, Chaplin, or family about your feelings and getting enough rest. Generally, you will find that each passing day will be better for you as you recover from your surgery.
Activity Time Between Surgery and Starting Activity
|Stationary bike||2 weeks||Mowing:Riding or Power||6 weeks|
|Driving||4 weeks||Bowling||8 weeks|
|Golfing: Putting or Wedge||6 weeks||Horseback Riding||8 weeks|
|Golfing: Full Swing||4 weeks||Skiing||8 weeks|
|Gardening||6 weeks||Running or Jogging||Based on rehab progress|
|Swimming||6 weeks||Snow Shoveling||Check with your doctor|
We recommend that you do not lift greater than 10 pounds for six weeks. Listen to your body. If it hurts to lift or you feel your chest “pulling,” do not do it. Remember, you have not used those muscles for a period of time so you will not have the strength you had before surgery.
After you get home, you will need to walk around. We recommend walking 4-6 times per day. The distance will depend on the patient. Some people walk 2-3 minutes at a time; some can walk 10 minutes at a time. Do what you can and increase your activity as tolerated. You will probably start cardiac rehabilitation approximately two weeks after discharge from the hospital. Below is a list of common activities. If the safety of an activity is uncertain, then check with your physician.
Unless your doctor advises otherwise, you may resume sexual intercourse as soon as you feel comfortable. Try to avoid positions that put weight on your breastbone or upper arms. If you are unsure, a guideline you may use is if you are able to walk 2 blocks or climb 2 flights of stairs without difficulty.
We recommend that you do not drive for at least four weeks after surgery. After that time, you have to be off your pain medicine and your spouse/family have to feel that you are “mentally alert” enough to drive. When you drive, put your heart pillow under the shoulder strap of your seatbelt to protect your incision. Note: The longer you wait to drive, the better.
Returning to work
Most people are required to be off work 4-6 weeks. Some people who work in an office setting may request to go back in two weeks. The necessary time off work will greatly depend on the physical requirements of your job and how you feel. Work releases are available upon request. Be sure your physician has a clear description of all the tasks you perform so he or she may release you accordingly.
Expectations after surgery
Every year over one half million Americans have coronary bypass surgery to relieve symptoms and prolong their lives. In the majority of people who have the surgery, the grafts remain open and functioning for 10 to 15 years.
CABG will improve blood flow to the heart but does not prevent the eventual recurrence of coronary blockage. Lifestyle changes are necessary -- such as not smoking, improved diet, weight loss, regular exercise, and treating high blood pressure and high cholesterol.