Coronary artery bypass graft (CABG) surgery is open heart surgery to improve the blood flow to the heart. It can relieve symptoms such as angina, improve your ability to exercise and reduce the chance of a heart attack.

The coronary arteries, the arteries that supply blood to the heart, can become narrowed or blocked, restricting the supply of oxygen and nutrients.

During bypass surgery, a new blood vessel is attached to the coronary artery from the aorta, your main artery coming from the heart. The new blood vessel is called a graft and is usually created from lengths of vein taken from your leg, arteries from your arm, or by diverting the internal mammary artery from the chest wall.

Blood is re-routed through this new vessel, bypassing the narrowed or blocked coronary vessel.

Most people have three grafts done during one operation but the range may be from one to six. The body will usually function perfectly well without the blood vessels used for the grafts.

Bypass surgery does not cure coronary artery disease, so it is possible for narrowing and blockages to recur in both the grafts and other coronary vessels.

The operation usually requires a hospital stay of 5-7 days. It is performed under general anaesthesia, which means you will be asleep during the procedure, and will feel no pain.

The operation lasts approximately three hours. If leg or arm veins are being used for grafts, these will be removed (harvested) and prepared first. Your surgeon will them make an incision, typically about 25cm long, down the middle of your breastbone (sternum) and open the ribcage to reach the heart.

The heart may be temporarily stopped using medication, and blood is re-routed to a heart-lung (bypass) machine. This takes over the pumping action of the heart and lungs, adding oxygen to the blood and maintaining the circulation.

With the heart not moving, the grafts are attached. Blood is then re-directed from the machine back to your heart, and the heart is restarted with small electrical shocks.

Occasionally, CABG is performed while the heart is still beating. Your surgeon can discuss the exact technique he recommends with you.

The breastbone is re-joined using wires and the skin on your chest is sealed using dissolvable stitches. Temporary drainage tubes are put into small holes in your chest to drain blood and fluid that collects as part of the normal healing process.

AFTER THE OPERATION

You will be taken from the operating theatre to the ITU where you will be closely monitored for around 24 hours. While you wake up from the anaesthesia, you will be connected to machines that record the activity of your heart, lungs and other body systems.

You may have a tube in your mouth, which passes into your windpipe, and is connected to a ventilator (a machine to help you breathe). This will be removed once you are alert and can breathe by yourself. A clip on your finger will measure the oxygen level in your blood.

Once you are stable, and the medical team are satisfied with your progress, you will be able to return to your private room.

RECOVERING FROM YOUR CORONARY ARTERY BYPASS GRAFT (CABG) SURGERY

Once you have returned to your room, your nurse will make you comfortable, monitor your heart rate, blood pressure and temperature at regular intervals and check your wounds.

It's normal to carry on getting oxygen through a plastic mask over your nose and mouth to help with your recovery. You will also have drips in your arms

MITRAL VALVE REPAIR & REPLACEMENT

The heart has 4 valves which maintain blood flows in the correct direction. The mitral valve lies between the upper (atrium) and lower (ventricle) heart chamber of the left side. This valve has 2 curtain like leaflets which open and close with every heartbeat. Both the leaflets are attached to the heart muscles with thread like structures called chords. The mitral valve may leak if there is a problem, through disease or infection, with the chords or leaflets or if the opening of the valve is enlarged.  Alternatively, the valve may be narrowed if the leaflets become thick and stiff and prevent blood flowing through the valve opening. In both of the cases you may have symptoms such as breathing difficulty or fainting episodes and you may need surgery to either repair or replace the mitral valve.

If you have a leaky mitral valve and if it is deemed to be repairable, then generally it is fixed or repaired by replacing the chords with artificial chords, repairing any abnormality of the leaflets and also by putting an artificial ring around the valve opening to support the repair and ensure long-term durability. 

If your mitral valve is not repairable then it will be replaced with a tissue valve (usually bovine in origin) or a mechanical valve (made from synthetic materials). Your surgeon will open a heart chamber, repair the valve or remove the faulty valve and sew in a replacement. The choice of whether a tissue or mechanical valve is best for you is made by yourself and your surgeon depending on your particular circumstances.

AORTIC VALVE REPLACEMENT & REPAIR

The aortic valve opens and closes to allow blood to flow out of the left upper chamber (ventricle) of the heart into the main artery (aorta) of the body. It usually consists of three leaflets, but many people are born with a 2 leaflet aortic valve. If they are damaged (through infection or disease) they either do not open properly so the valve opening is narrowed (aortic stenosis) or do not close tightly enough and the valve leaks (aortic regurgitation). Most valves become narrowed due to wear and tear over many decades which results in calcium building up on the valve and the leaflets becoming stiff and unable to open fully. Both problems mean the heart has to pump harder. A new valve will relieve this strain and aims to ease symptoms such as breathlessness and chest pain due to angina. This will enable you to live a longer life and you will have a reduced risk of developing heart failure. Your operation involves replacing a damaged valve in your heart with a mechanical valve (made from synthetic materials) or a tissue valve (usually bovine in origin). Your surgeon will open the aorta, remove the faulty valve and sew in a replacement. The choice of whether a tissue or mechanical valve is best for you is made by yourself and your surgeon depending on your particular circumstances.

TRICUSPID VALVE REPAIR or REPLACEMENT

The tricuspid valve is one of 2 valves on the right side of your heart. The tricuspid valve controls blood flow from the heart into the lungs where the blood becomes oxygenated. The tricuspid valve can become diseased by infection and other diseases of the heart. Most commonly this results in a valve which becomes incompetent resulting in regurgitation of blood backwards, but a narrowing or stenosis of the valve can also develop in more rare disorders of the heart. In some patients a repair of the tricuspid valve is required because there is another valve problem. Most commonly it is associated with incompetence of the mitral valve or when there is also a disturbance of the heart rhythm.

The first choice of your surgeon will always be to try and repair an incompetent tricuspid valve even when it is due to infection, but a narrowed tricuspid valve may require a replacement. It is important to restore normal tricuspid valve function as it will reduce the risk of future heart failure and thereby increase your lifespan. Valve repairs usually involve implanting an artifcial ring around the tricuspid valve, which helps to restore it’s normal shape and support a long-term successful outcome. If a valve replacement is required then the choice is between a tissue valve made from animal material (usually bovine) or a prosthetic valve made only from man made materials. All prosthetic valve require anticoagulation for life with warfarin. Your surgeon will discuss all the options with you and make the best recommendation for your heart problem.

ABOUT HEART VALVE OPERATIONS

The operation typically requires a hospital stay of 5-7 seven days and is done under general anaesthesia. This means you will be asleep during the procedure. Once the anaesthetic has taken effect, your surgeon will make a cut, down the middle of your breastbone and open the chest to reach the heart. The heart is slowed or stopped (using medication) and blood is re-routed to a heart-lung machine. This takes over the pumping action of the heart and lungs, adding oxygen to the blood and maintaining the circulation. Your surgeon will open a chamber (right atrium) on the right side of the heart and repair or replace the tricuspid valve. Blood is then redirected back to your heart and the heart is restarted. The breastbone is re-joined using wires and your chest is closed using either dissolvable sutures, stitches or staples. The operation usually takes about 2-3 hours.

AFTER THE OPERATION

You will be taken from the operating theatre to the ITU where you will be closely monitored for around 24 hours. When you wake up from the anaesthesia, you will be connected to machines that record the activity of your heart, lungs and other body systems.

You may have a tube in your mouth, which passes into your windpipe, and is connected to a ventilator (a machine to help you breathe). This will be removed once you are alert and can breathe by yourself. A clip on your finger will measure the oxygen level in your blood.

Once you are stable and the medical team are satisfied with your progress, you will be able to return to your private room.

The aorta is the main artery which arises from the heart and the branches from the aorta supply the organs and tissues of the whole body. The aorta can be affected by diseases which results in a weakening of the wall and gradual enlargement of its size. Many people have a slightly enlarged aorta which is harmless but when it becomes too large then it may form a balloon like appearance or aneurysm. Any segment of the aorta can become aneurysmal or the whole aorta can be enlarged. As the aorta enlarges, the wall of the aorta also thins out, and like an over-inflated balloon, there is a high risk of it bursting. The wall of the aorta is also made of layers and sometimes the increase stress on the wall can cause the layers to fall apart. This is called a dissection. Therefore, a large aortic aneurysm is life threatening and rupturing of the aorta is a catastrophic event. Surgery is usually aimed at avoiding this by replacing the affected part of the aorta with a synthetic tube made out of a strong material called Dacron.

Surgery on the aorta is usually divide into its segments (see illustration).

Although operations can be limited to one segment, it usually involves the neighbouring segments. For instance, the aortic root commonly involves the ascending aorta; the aortic arch commonly involves the ascending aorta and descending thoracic aorta; and occasionally operations are done on the thoracic aorta, or the thoracic and abdominal (thoracoabdominal) aorta at the same time.

The team has the experience and expertise to operate on all segments of the aorta, using state of the art techniques.

SURGERY ON THE AORTIC ROOT

The aortic root is the first part of the aorta and is directly connected to the heart. It composes of the aortic valve (the outlet valve of the heart), and the aortic sinuses (where the arteries that take blood to the heart itself arises from). When this part of the aorta gets too big, it is called an aortic root aneurysm and it is often associated with problems of the aortic valve. When the aortic root aneurysm reaches a certain size (generally about 5cm), the danger of it rupturing is excessively high and it would be recommended that you would have it replaced. It may be decided that you should have an operation with a smaller aneurysm if you have risk factors such as Marfan Syndrome or a strong family history of the aorta tearing.

The wall of the aorta will be replaced by an artificial tube made out of Dacron and the coronary arteries will be reattached onto this new tube. If the associated aortic valve problem is one of stenosis (narrowing), the valve is usually replaced with a new artificial valve (this is called an aortic root replacement). If the aortic valve is normal or leaking, it may be possible to preserve your valve. This is called an aortic root repair or a valve sparing aortic root replacement. Your surgeon will explain this to you in as much detail as you would wish to know during the consultation.

SURGERY OF THE ASCENDING AORTA

Surgery of the ascending aorta on its own is uncommon. It is usually performed in association with surgery of the aortic root or aortic arch. Not uncommonly though, it may need replacing in surgery for bicuspid aortic valve problems.

SURGERY OF THE ARCH OF THE AORTA

The aortic arch gives off the arteries to the brain, head, neck and arms. As a result, surgery to replace this part of the aorta can be quite complicated as we would need to employ operative strategies, whilst we are replacing the arch of the aorta, that maintain a blood supply to your brain to avoid a stroke and also to avoid injury to other important organs such as your liver and kidneys. This type of surgery usually involves cooling your body down to a low temperature so that we can stop the blood supply to these organs for a short period of time without causing any injury. This is known technically as deep hypothermic circulatory arrest.

Surgery to replace the aortic arch usually also involves replacing part of the ascending aorta and descending thoracic aorta. Nowadays. If there is an associated aneurysm of the descending thoracic aorta, this may also be repaired with a stent at the time of the procedure using new devices known as hybrid grafts (Dacron grafts with a stent incorporated, also known as frozen elephant trunks).

SURGERY OF THE DESCENDING THORACIC AND THORACOABDOMINAL AORTA

As well as open surgery to replace these parts of the aorta, there may be other treatment options such as stenting, also known as thoracic endovascular aortic repair or TEVAR, or a combination of open surgery and TEVAR. The advantage of TEVAR is that it is much less invasive than open surgery and recovery from the procedure will be much quicker. Your case will usually be discussed by a team dedicated to treat these conditions to decide the best option to treat your aneurysm. Your surgeon will then explain this in detail to you at the consultation.

Open surgery to replace the descending thoracic and thoracoabdominal aorta is usually an extensive operation and there are only a few surgeons in this country that will perform them. Southampton is one of the few centres, which has the whole expertise, in this country that performs these types of operations. These operations are usually done through an incision on the side of the chest and because the normal blood supply will be interrupted for a short period of time to some of your vital organs, special techniques will be used to maintain blood flow to them and also to protect them during the operation. Your surgeon will explain these and also the potential complications of the operation to you at the time of the consultation.

WHAT TO EXPECT AFTER AORTIC SURGERY

Surgery of the aortic root and ascending aorta is very much like other operations on the heart such as coronary bypass surgery and surgery to replace or repair heart valves. You will usually stay one night in the intensive care unit before stepping down to a high dependency unit or directly to the ward depending on your rate of recovery. Over the subsequent days, you will become more mobile and independent and when the medical, nursing and physiotherapy teams are happy with your recovery, you will be discharged home usually around seven days after the operation. You will be monitored very closely throughout the whole recovery period. At discharge, you should be able to mobilise, including climbing one flight of stairs, independently. You should also be able to shower and toilet yourself and although you would not need anyone to nurse you, it would be useful to have someone with you at home, but this does not need to be continuously. The medications that you will need to take at home will be carefully explained to you.

A similar process takes place with surgery of the aortic arch, thoracic and thoracoabdominal aorta but because surgery for these parts of the aorta are more extensive and complex, we would expect your recovery time to be longer. For surgery of the aortic arch we would anticipate that you will stay for approximately 10 days, and for surgery of the thoracic or thoracoabdominal aorta we would anticipate a stay of approximately 14 days.

The nursing and physiotherapy teams will explain further to you before discharge as to what to expect when you are at home, and things to do to continue your recovery. You will be reviewed in the clinic to check on your recovery at approximately 8 weeks following discharge but there is always a team at hand to give telephone advice and earlier review in the clinic can be arranged at any time if necessary.

Disturbances of the heart rhythm are quite common and increase with age. The are many types of heart rhythm abnormalities but the most common is a condition called atrial fibrillation (AF). There are about 1 million people in the UK with AF and it is thought to be cause of 1 in 5 strokes. This is the only heart rhythm disturbance which is referred for surgical correction. Usually because the patient needs another type of operation on the heart at the same time.

Patients who have AF often present with breathless and dizziness and can feel their heartbeat being irregular; many people have no symptoms and are picked up by routine examination. The pulse appears to be “random” so it is totally irregular. That is because 2 out of the 4 chambers of the heart are beating completely randomly and out of time with the main 2 other pumping chambers of the heart. This results in the heart becoming very much less efficient as a pump so the patients experiences limitation of activities. The blood may also become stagnant inside the 2 chambers which are beating randomly which put’s patients at increased risk of clots forming inside the heart. If these clots are pumped out of the heart to the brain then it may cause a stroke. For this reason the patients are put onto drugs which thin or anticoagulate the blood to reduce this risk. Some patients may have already undergone procedures in the catheter laboratory to try and convert their AF back to a regular rhythm; in some patients this is not successful and if they are still are affected by symptoms not controlled by drugs then they will be referred for a surgical correction.

SURGICAL CORECTION OF ATRIAL FIBRILLATION

As previously mentioned this is usually undertaken when the patient requires another heart procedure such a s valve operation or a bypass graft operation for diseased arteries, but the procedure itself is the same. The operation typically requires a hospital stay of 5-7 seven days and is done under general anaesthesia. This means you will be asleep during the procedure. Once the anaesthetic has taken effect, your surgeon will make a cut, down the middle of your breastbone and open the chest to reach the heart. The heart is slowed or stopped (using medication) and blood is re-routed to a heart-lung machine. This takes over the pumping action of the heart and lungs, adding oxygen to the blood and maintaining the circulation. Depending on what type of AF surgery you require and what other heart procedure is planned, your surgeon may or may not open the heart chambers. The procedure involves making ablation lines across the veins of the heart and the chambers of the heart itself. Ablation lines are created by causing injury to the tissues so when it heals by scarring, the heart rhythm is directed down a controlled route. This then prevents the heart from beating in an irregular way and causing AF. This is undertaken by 2 energy sources radiofrequency (heat injury) and cryotherapy (cold injury). To complete the AF surgery, your surgeon will close of an appendage of the heart called the left atrial appendage – this is to reduce the risk of clot forming inside the heart which may cause a stroke. Blood is then redirected back to your heart and the heart is restarted. The breastbone is re-joined using wires and your chest is closed using either dissolvable sutures, stitches or staples. The operation usually takes about 2-3 hours.

AFTER THE OPERATION

You will be taken from the operating theatre to the ITU where you will be closely monitored for around 24 hours. When you wake up from the anaesthesia, you will be connected to machines that record the activity of your heart, lungs and other body systems.

You may have a tube in your mouth, which passes into your windpipe, and is connected to a ventilator (a machine to help you breathe). This will be removed once you are alert and can breathe by yourself. A clip on your finger will measure the oxygen level in your blood.

Once you are stable and the medical team are satisfied with your progress, you will be able to return to your private room.

An alternative to conventional cardiac surgery is minimally invasive heart surgery, which is undertaken using small incisions in the right and/or left side of your chest to reach the heart. Conventional surgery divides the breastbone, while minimally invasive surgery separates spaces between ribs to gain access to the heart. With conventional surgery only one incision in the middle is required, while multiple small incisions are required for minimally invasive surgery.

Many types of heart procedures may be conducted with minimally invasive heart surgery, including:

• Mitral valve repair or replacement
• Tricuspid valve repair or replacement
• Aortic valve replacement
• Maze procedure for atrial fibrillation
• Coronary artery bypass surgery
• Transcatheter Aortic Valve Implantation (TAVI)
• Endoscopic vein harvesting (EVH) for coronary artery bypass surgery

Minimally invasive surgery involves inserting a small video camera through one of the incisions will enables the surgeon to see inside your body. Like conventional heart surgery, most minimally invasive procedures use a heart-lung bypass machine, as is used in open-heart surgery. During this procedure, your surgeon works either at from a high resolution video monitor or by direct vision.

Potential benefits

Your surgeon will discuss with you if you are suitable for minimal access heart surgery. The potential benefits when compared with open-heart surgery can include:

• Less blood loss
• Lower risk of infection
• Potential to reduce trauma and pain
• Shorter time in the hospital, faster recovery and quicker return to normal activities
• Smaller, less noticeable scars

However, it is important to stress that there are no differences in long-term outcomes with either conventional or minimal access approaches. The most important factor to consider is how best to deliver the highest quality heart operation to repair your heart and return you to full activities.

Transcatheter Aortic Valve Implantation (TAVI)

This technique is often referred to as TAVI or Transcatheter Aortic Valve Replacement (TAVR) in North America. This a technique which is used for the treatment of aortic stenosis (a narrowed aortic valve) but is not suitable for aortic regurgitation (an aortic valve which is leaking). TAVI is the implantation of a tissue aortic valve inside an existing diseased aortic valve. The technique has grown in popularity across the World but in the UK the minority of aortic valve disease is treated by TAVI. Currently the evidence for using TAVI for high risk patients is strong, but is not so compelling for medium and low risk patients. The long-term data on the durability of TAVI valves remains limited and it is associated with increased risk of needing a pace-maker to be implanted and also there is increased risk of a leak around the TAVI valve.

Your surgeon will advise you if you are a suitable patient for this approach. If you are to be considered for this approach, you will need to undergo a body CT scan to assess the size and quality of your main arteries. There are 2 main routes for delivering a TAVI valve. The most common approach is the deliver the valve under local anaesthetic via a catheter inserted into an artery in the groin. For a minority of patients, this is not possible due to diseased arteries in the groin or in the abdomen or chest. For these patients a trans-apical (TA-TAVI), can be undertaken. This has to be undertaken under general anaesthetic with a small incision being made in the left side of the chest to introduce a catheter directly into the apex of the heart to deliver the TAVI valve.

The main advantage of a TAVI approach is that cardiopulmonary (heart-lung) bypass can be avoided and for many patients, it can be undertaken using local anaesthetic. This facilitates more rapid recovery, mobilisation and return to normal activities.

https://www.youtube.com/watch?v=8wJoSNQ-Dek&feature=youtu.be

Endoscopic Vein Harvesting for Coronary Artery Bypass Surgery

Endoscopic vein harvesting or EVH is undertaken for patients who have suitable veins for harvesting with this technique and require a Coronary Artery Bypass Grafting (CABG) operation to increase blood flow for narrowed or blocked arteries of the heart. Normally vein is harvested from the leg as an open procedure, with an incision which is as long as the vein harvested. The amount of vein harvested will be determined by how many grafts need to be constructed and the quality of the vein. Vein may need to be taken from both legs if the quality of the vein is inadequate. One or more arteries are also be harvested for CABG, but for the purposes of this discussion we will focus on vein harvesting.

EVH involves making a small cut just above the knee and an endoscope is inserted, which is a long, thin flexible tube with a camera. An image is then projected onto a screen so your surgeon can locate and remove the vein. Two more small cuts are also made near the groin and/or ankle to help remove the vein.

The EVH technique results in reduced wound/ scar length compared to the more traditional method. Studies have also shown that EVH reduces the risk of infection or wound problems, particularly in patients with diabetes. EVH causes less pain and swelling after the procedure, which allows patients to mobilise faster. This then facilitates earlier commencement of a cardiac rehabilitation programme.

After the Operation

You will be taken from the operating theatre to the ITU where you will be closely monitored for around 24 hours. When you wake up from the anaesthesia, you will be connected to machines that record the activity of your heart, lungs and other body systems.

You may have a tube in your mouth, which passes into your windpipe, and is connected to a ventilator (a machine to help you breathe). This will be removed once you are alert and can breathe by yourself. A clip on your finger will measure the oxygen level in your blood.

Once you are stable and the medical team are satisfied with your progress, you will be able to return to your private room.

Visit ctsurgerypatients.org for more information.