Coronary bypass surgery

Heart bypass surgery, known medically as coronary artery bypass grafting, is a very common surgical procedure that has been successfully performed since the 1970's. In Israel alone 4,000 such procedures are performed annually.

What medical symptoms require bypass surgery?

Bypass surgery is an operational solution that might be compatible for patients suffering from cardiac-type atherosclerosis. Atherosclerosis is a term used to describe any narrowing of the arteries caused by the buildup of fatty tissue (which contains among other things cholesterol, calcium and other cell debris) in the artery that controls the supply of blood to the heart. This build up of fatty tissue leads to a thickening and narrowing of the coronary arteries and eventually could cause heart attacks, brain strokes and other fatal vascular diseases. Not every advanced stage of atherosclerosis requires bypass surgery; in some cases the condition can be managed by opening the cardiac arteries via cardiac catheterization, followed sometimes by the insertion of a stent that will prevent the arteries from clogging up again. However, there are some cases where the blocked artery cannot be opened by cardiac catheterization. Such a situation can occur due to the nature or location of the arterial blockage, or when a cardiac catheterization was performed but the blockage could not be opened, or when it is known that due to the scope and degree of the blockage, bypass surgery would be the treatment of choice. Bypass surgery can also be performed as an emergency operation after a severe heart attack.

There are a few medical symptoms that require bypass surgery: severe stenosis or narrowing of the left main coronary artery, acute atherosclerosis of the three cardiac blood vessels, severe left ventricular failure and an artery condition combined with a valve disorder. In any case, prior to making the decision of undergoing surgery it is important to consult with Cardioheal's doctors (a cardiac surgeon and cardiologist), who are experts at treating such medical conditions.. Together, it will be possible to discuss the various types of cardiac surgical interventions, possible treatments, their respective advantages and disadvantages, and the degree of compatibility of each treatment to the individual patient's condition.

The Procedure

Bypass surgery is done under general anesthesia and can be performed by a number of techniques. The traditional method is by opening the chest via a median sternotomy (meaning the sternum itself is divided, or "cracked"), and a heart-lung machine is connected to the patient. There is, however, a newer technique in which surgery is performed with a beating heart called an off-pump coronary artery bypass, which is used instead of connecting the patient to a heart-lung machine. An even newer technique comprises minimally-invasive bypass surgery in which the operation is done without opening the sternum and is called minimally-invasive direct coronary artery bypass surgery. The decision as to which surgical method to use is dependent upon many factors, including: the condition of the patient's heart and arteries, the general outlines for the procedure and the surgeon's experience regarding the different techniques.

Minimally-invasive bypass surgery is designated only for cases of bypass surgery involving the left anterior descending artery. Initially, the surgeon will cut open the patient's sternum and, if the traditional technique has been chosen, the patient's heart will be connected to a heart-lung machine, while the normal heart beats will be stopped throughout the entire procedure. The heart-lung machine replaces the heart's function as a pump, and the lung's capacity to oxygenate the blood, thereby maintaining the body's normal functions.

When performing bypass surgery on a beating heart, the patient's heart will beat normally throughout the entire procedure. By using a number of stabilizers the surgeon has easy access to the blocked artery alone without disrupting the normal function of the heart. For the bypass itself, harvested veins removed from the lower extremities are used together with harvested arteries, which usually originate from the breast arteries located in the chest. All these procedures will be governed by the number of bypasses needed and which arteries are being targeted.

After the blocked area of the coronary artery has been identified, the surgeon will stitch the end of the harvested vein or artery graft onto the coronary artery beyond the blockage. After creating bypasses to all of the blockages via the new blood vessels, the patient's heart, either independently or via an electric shock from a defibrillator, will be returned to its normal function and the patient will be taken off the heart-lung machine. Following this, the sternum is wired together, the incisions are sutured closed by the surgeon, and the patient is transferred to the intensive care unit.

What should be expected immediately after surgery?

Immediately after surgery the ventilated and sedated patient is moved to the intensive care unit. During the first few days and depending upon the type of surgery, the patient will gradually be disconnected from the ventilating machine. Once the patient is stabilized, he/she will be transferred to a cardiac surgery ward for further care, and from there to one of the recovery wards of his/her choice and the approval of the HMO with whom he/she is insured.

A patient who arrives for treatment at an early stage of the diagnosis before it is too late to intervene surgically, can expect to return to a regular life style, including full physical exercise, sports, trips abroad and a normal way of life. The patient will be placed under long-term follow-up by the Cardioheal cardiologists, and will be able to schedule private consultations whenever necessary.

To coordinate a private consultation or operation – please fill out the contact form.

Are there any risks involved in undergoing bypass surgery?

Much like any invasive surgical procedure, bypass surgery is not without risk and complications, and it is important to be aware of this prior to making any decision to undergo surgery. In order to reduce those possible risks and complications, it is highly advisable to provide the surgeon and anesthesiologist with all your personal and medical history so that they can recommend the best treatment compatible with your specific medical background.

Any elective surgery (i.e. non-emergency surgery) is considered a relatively safe procedure, which has a relatively very low mortality rate (about 1%), as well as low complication risks. However, patients suffering from left ventricular systolic dysfunction, patients who have undergone a myocardial infarction resulting in an impaired heart muscle, patients suffering from cardiovascular diseases, or from chronic obstructive pulmonary disease, are considered to be at high risk for surgery. Risk from anesthesia is also relatively low.

Anesthesia & sedation

Bypass surgery is performed under general anesthesia. This allows patients to undergo the entire procedure without the distress and pain they would otherwise experience. Anesthesia is generally administered by an intravenous injection. Moments later the patient will fall into a state of drowsiness, followed by semi-consciousness and then a deep sleep. An anesthesiologist monitors the patient's medical condition at all times to insure that he/she is in a state of deep sleep, that the muscles are completely relaxed and that a state of total lack of awareness is maintained. After the surgical part of the operation is completed the anesthesiologist wakes the patient up by halting the administration of the anesthetics. Once the patient is awake, he/she is transferred to the recovery ward in order to insure a safe and monitored recovery period.

Important information needed prior to surgery

In preparation for valve repair or replacement surgery the patient must undergo a complete blood count, which includes the following: a biochemical analysis, electrolyte, liver function and blood clotting tests. An ECG and chest x-ray will also be performed. Furthermore, the patient will also need to have in his possession all the cardiac imaging tests that were performed, such as the diagnostic cardiac catheterization/virtual catheterization, cardiac CT, cardiac stress test etc. It is important for the patient to prepare an entire medical portfolio in order to be able to share his/her entire medical history with the surgeon and the anesthesiologist. It is especially important that the medical team be informed of prior surgical procedures and hospital admissions, chronic ailments, prescription drugs, diet supplements and allergies. Patients who suffer from secondary ailments are required to a consult with their individual specialists (e.g. internist, gynecologist, dermatologist) prior to undergoing surgery. One week prior to surgery and in accord with the surgeon's recommendations, the patient should stop taking anticoagulation drugs such as Coumadin. It is important to confer with your family physician or your surgeon regarding substitutes. On the day of the operation, from 6 hours prior to surgery, the patient must be on a complete fast, including water intake. Before surgery, dentures, jewelry and personal items of clothing will be removed by a staff member, and it is advised to refrain from smoking. Should the operating site include bodily hair, this will be shaved off by a hospital staff member. It is advised to shower afterwards. Moments before the surgery, the patient will be hooked up to an infusion into which the anesthesiologist will introduce sedatives that will assist in relieving anxiety and stress.

Recuperation and recovery from bypass surgery

After a short stay in an intensive care unit, the patient will be transferred to a cardiac surgery ward where he/she will receive continued treatment from the medical and nursing staff. This will include general care and continuous heart monitoring by an ECG monitor connected to the body. A few hours later the patient will be assisted in getting off the bed in order to sit in an armchair. Based on professional medical literature, about 85% of patients experience a substantial improvement in their quality of life after surgery. Nevertheless, it is important to take into consideration the fact that recovery is a gradual and prolonged process taking 3- 4 months.

During the first days after hospital discharge most patients feel weak due to the trauma of the surgery. It is recommended to increase activity levels gradually: start off by doing small tasks that require no physical effort or strain, and gradually pace yourself up in accordance with your general feeling.

About two weeks after surgery an appointment will be scheduled with the patient in order to review current status with one of Cardioheal's doctors. At this time, it is important to inform the doctor of any new sensations or medical conditions that have arisen and update him about your general current state of health. If a patient has a fever over 38°C, or if he/she suffers from chest pain or any other alarming symptom, the surgeon or nurse on call must be informed immediately and without delay. It is recommended that the patient should not engage in any heavy lifting or strained physical exercise during the first 6 to 8 weeks following surgery. Should the patient suffer from dizziness or fatigue, it is also recommended to abstain from driving until these sensations pass. It is usually recommended to take sick leave from work for a period of 2 months.

Joining a cardiac rehabilitation program is also recommended and might assist and improve the recovery process. The initial rehabilitation period is generally provided at hotels or designated centers, and later at community clinics or hospitals. A rehabilitation period is highly recommended since it provides education and guidance in healthy nutrition, a custom-made exercise plan, and a general individual care and monitored program.

The duration of the surgery and hospital stay

Duration of surgery and the hospital stay are individual in nature and depend upon the type of surgery and the medical condition of the patient. Generally speaking, surgery can last from 3- 6 hours, including the anesthesia, while hospital stay is about 5 days, but can be longer in certain cases.

To coordinate a private consultation or operation – please fill out the contact form.