Heart bypass surgery
Heart bypass surgery creates a new route, called a bypass, for blood and oxygen to go around a blockage to reach your heart.
Before your surgery, you will get general anesthesia. You will be asleep (unconscious) and pain-free during surgery.
Once you are unconscious, the heart surgeon will make an 8 to 10-inch (20.5 to 25.5 cm) surgical cut in the middle of your chest. Your breastbone will be separated to create an opening. This allows your surgeon to see your heart and aorta, the main blood vessel leading from the heart to the rest of your body.
Most people who have coronary bypass surgery are connected to a heart-lung bypass machine, or bypass pump.
- Your heart is stopped while you are connected to this machine.
- This machine does the work of your heart and lungs while your heart is stopped for the surgery. The machine adds oxygen to your blood, moves blood through your body, and removes carbon dioxide.
Another type of bypass surgery does not use the heart-lung bypass machine. The procedure is done while your heart is still beating. This is called off-pump coronary artery bypass, or OPCAB.
To create the bypass graft:
- The doctor will take a vein or artery from another part of your body and use it to make a detour (or graft) around the blocked area in your artery. Your doctor may use a vein, called the saphenous vein, from your leg.
- To reach this vein, a surgical cut will be made along the inside of your leg, between your ankle and groin. One end of the graft will be sewn to your coronary artery. The other end will be sewn to an opening made in your aorta.
- A blood vessel in your chest, called the internal mammary artery (IMA), can also be used as the graft. One end of this artery is already connected to a branch of your aorta. The other end is attached to your coronary artery.
- Other arteries can also be used for grafts in bypass surgery. The most common one is the radial artery in your wrist.
After the graft has been created, your breastbone will be closed with wires. These wires stay inside you. The surgical cut will be closed with stitches.
This surgery can take 4 to 6 hours. After the surgery, you will be taken to the intensive care unit.
Why the Procedure is Performed
You may need this procedure if you have a blockage in one or more of your coronary arteries. Coronary arteries are the vessels that supply your heart with oxygen and nutrients that are carried in your blood.
When one or more of the coronary arteries becomes partly or totally blocked, your heart does not get enough blood. This is called ischemic heart disease, or coronary artery disease (CAD). It can cause chest pain (angina).
Coronary artery bypass surgery can be used to improve blood flow to your heart. Your doctor may have first tried to treat you with medicines. You may have also tried exercise and diet changes, or angioplasty with stenting.
CAD is different from person to person. The way it is diagnosed and treated will also vary. Heart bypass surgery is just one type of treatment.
Other procedures that may be used:
Risks for any surgery include:
Possible risks from having coronary bypass surgery include:
- Infection, including chest wound infection, which is more likely to happen if you are obese, have diabetes, or have already had this surgery
- Heart attack
- Heart rhythm problems
- Kidney failure
- Lung failure
- Depression and mood swings
- Low fever, tiredness, and chest pain, together called postpericardiotomy syndrome, which can last up to 6 months
- Memory loss, loss of mental clarity, or "fuzzy thinking"
Before the Procedure
Always tell your health care provider what drugs you are taking, even drugs or herbs you bought without a prescription.
During the days before your surgery:
- For the 1-week period before surgery, you may be asked to stop taking drugs that make it harder for your blood to clot. These might cause increased bleeding during the surgery. They include aspirin, ibuprofen (such as Advil and Motrin), naproxen (such as Aleve and Naprosyn), and other similar drugs. If you are taking clopidogrel (Plavix), talk with your surgeon about when to stop taking it.
- Ask which drugs you should still take on the day of the surgery.
- If you smoke, try to stop. Ask your provider for help.
- Contact your provider if you have a cold, flu, fever, herpes breakout, or any other illness.
- Prepare your home so you can move around easily when you return from the hospital.
The day before your surgery:
- Shower and shampoo well.
- You may be asked to wash your whole body below your neck with a special soap. Scrub your chest 2 or 3 times with this soap.
- Make sure that you dry yourself off.
On the day of the surgery:
- You will be asked not to drink or eat anything after midnight the night before your surgery. Rinse your mouth with water if it feels dry, but be careful not to swallow.
- Take any medicines that you have been told to take with a small sip of water.
You will be told when to arrive at the hospital.
After the Procedure
After the operation, you will spend 3 to 7 days in the hospital. You will spend the first night in an intensive care unit (ICU). You will probably be moved to a regular or transitional care room within 24 to 48 hours after the procedure.
Two to three tubes will be in your chest to drain fluid from around your heart. They are most often removed 1 to 3 days after surgery.
You may have a catheter (flexible tube) in your bladder to drain urine. You may also have intravenous (IV) lines for fluids. You will be attached to machines that monitor your pulse, temperature, and breathing. Nurses will constantly watch your monitors.
You may have several small wires that are connected to a pacemaker, which are pulled out prior to your discharge.
You will be encouraged to restart some activities and you may begin a cardiac rehab program within a few days.
It takes 4 to 6 weeks to start feeling better after surgery. Your providers will tell you how to take care of yourself at home after the surgery.
Recovery from surgery takes time. You may not see the full benefits of your surgery for 3 to 6 months. In most people who have heart bypass surgery, the grafts stay open and work well for many years.
This surgery does not prevent the coronary artery blockage from coming back. You can do many things to slow this process down, including:
- Not smoking
- Eating a heart-healthy diet
- Getting regular exercise
- Treating high blood pressure
- Controlling high blood sugar (if you have diabetes) and high cholesterol
Off-pump coronary artery bypass; OPCAB; Beating heart surgery; Bypass surgery – heart; CABG; Coronary artery bypass graft; Coronary artery bypass surgery; Coronary bypass surgery; Coronary artery disease – CABG; CAD – CABG; Angina – CABG
Heart bypass surgery – discharge
Heart bypass surgery creates a new route, called a bypass, for blood and oxygen to go around a blockage to reach your heart. The surgery is used to treat coronary heart disease. This articles discusses what you need to do to care for yourself when you leave the hospital.
When you Were in the Hospital
Your surgeon took a vein or artery from another part of your body to create a detour, or bypass, around an artery that was blocked and could not bring enough blood to your heart.
Your surgery was done through an incision (cut) in your chest. If the surgeon went through your breastbone, the surgeon repaired it with wire and a metal plate, and your skin was closed with stitches. You also had an incision made in your leg or arm, where the vein was taken to be used for the bypass.
What to Expect at Home
After surgery, it takes 4 to 6 weeks to completely heal and start feeling better. It is normal to:
- Have pain in your chest area around your incision
- Have a poor appetite for 2 to 4 weeks
- Have mood swings and feel depressed
- Have swelling in the leg that the vein graft was taken from
- Feel itchy, numb, or tingly around the incisions on your chest and leg for 6 months or more
- Have trouble sleeping at night
- Be constipated from pain medicines
- Have trouble with short-term memory or feel confused ("fuzzy-headed")
- Be tired or not have much energy
- Have some shortness of breath. This may be worse if you also have lung problems. Some people may use oxygen when they go home.
- Have weakness in your arms for the first month
You should have someone stay with you in your home for at least the first 1 to 2 weeks after surgery.
Learn how to check your pulse, and check it every day.
Do the breathing exercises you learned in the hospital for 4 to 6 weeks.
Shower every day, washing the incision gently with soap and water. DO NOT swim, soak in a hot tub, or take baths until your incision is completely healed. Follow a heart-healthy diet.
If you feel depressed, talk with your family and friends. Ask your health care provider about getting help from a counselor.
Continue to take all your medicines for your heart, diabetes, high blood pressure, or any other conditions you have.
- DO NOT stop taking any medicine without first talking with your provider.
- Your provider may recommend antiplatelet (blood-thinning) drugs such as aspirin, clopidogrel (Plavix), prasugrel (Effient), or ticagrelor (Brilinta) to help keep your artery graft open.
- If you are taking a blood thinner, such as warfarin (Coumadin), you may need to have extra blood tests to make sure your dose is correct.
Stay active during your recovery, but start slowly.
- DO NOT stand or sit in the same spot for too long. Move around a little bit.
- Walking is a good exercise for the lungs and heart after surgery. DO NOT be concerned about how fast you are walking. Take it slow.
- Climbing stairs is OK, but be careful. Balance may be a problem. Rest halfway up the stairs if you need to.
- Light household chores, such as setting the table, folding clothes, walking, and climbing stairs, should be OK.
- Slowly increase the amount and intensity of your activities over the first 3 months.
- DO NOT exercise outside when it is too cold or too hot.
- Stop if you feel short of breath, dizzy, or any pain in your chest. DO NOT do any activity or exercise that causes pulling or pain across your chest, such as using a rowing machine or weight lifting.
- Keep your incision areas protected from the sun to avoid sunburn.
DO NOT drive for at least 4 to 6 weeks after your surgery. The twisting involved in turning the steering wheel may pull on your incision. Ask your provider when you may return to work, and expect to be away from work for about 6 to 8 weeks.
DO NOT travel for at least 2 to 4 weeks. Ask your provider when travel is OK. Also ask your provider before starting sexual activity again. Most of the time it is OK after 4 weeks.
You may be referred to a formal cardiac rehabilitation program. You will get information and counseling regarding activity, diet, and supervised exercise.
For the first 6 weeks after your surgery, you must be careful about using your arms and upper body when you move.
- DO NOT reach backward.
- DO NOT let anyone pull on your arms for any reason — for instance, if they are helping you move around or get out of bed.
- DO NOT lift anything heavier than 5 to 7 pounds (2 to 3 kilograms).
- DO NOT do even light housework for at least 2 to 3 weeks.
- Check with your provider before using your arms and shoulder more.
Brushing your teeth is OK, but DO NOT do other activities that keep your arms above your shoulders for any period of time. Keep your arms close to your sides when you are using them to get out of bed or a chair. You may bend forward to tie your shoes. Always stop if you feel pulling on your breastbone.
Your provider will tell you how to take care of your chest wound. You will likely be asked to clean your surgical cut every day with soap and water, and gently dry it. DO NOT use any creams, lotions, powders, or oils unless your provider tells you it is OK.
If you had a cut or incision on your leg:
- Keep your legs raised when sitting.
- Wear elastic TED hose for 2 to 3 weeks until the swelling goes away and you are more active.
When to Call the Doctor
Call your provider if:
- You have chest pain or shortness of breath that does not go away when you rest.
- Your pulse feels irregular — it is very slow (fewer than 60 beats a minute) or very fast (over 100 to 120 beats a minute).
- You have dizziness, fainting, or you are very tired.
- You have a severe headache that does not go away.
- You have a cough that does not go away
- You are coughing up blood or yellow or green mucus.
- You have problems taking any of your heart medicines.
- Your weight goes up by more than 2 pounds (1 kilogram) in a day for 2 days in a row.
- Your wound changes. It is red or swollen, it has opened, or there is more drainage coming from it.
- You have chills or a fever over 101°F (38.3°C).
Off-pump coronary artery bypass – discharge; OPCAB – discharge; Beating heart surgery – discharge; Bypass surgery – heart – discharge; CABG – discharge; Coronary artery bypass graft – discharge; Coronary artery bypass surgery – discharge; Coronary bypass surgery – discharge; CAD – bypass discharge; Coronary artery disease – bypass discharge
- How to take your wrist pulse
- Taking your carotid pulse
Fihn SD, Blankenship JC, Alexander KP, et al. 2014 ACC/AHA/AATS/PCNA/SCAI/STS focused update of the guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines, and the American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation. 2014;130(19):1749-1767. PMID: 25070666 www.ncbi.nlm.nih.gov/pubmed/25070666.
Fihn SD, Gardin JM, Abrams J, et al. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation. 2012;126(25):3097-3137. PMID: 23166210 www.ncbi.nlm.nih.gov/pubmed/23166210.
Fleg JL, Forman DE, Berra K, et al. Secondary prevention of atherosclerotic cardiovascular disease in older adults: a scientific statement from the American Heart Association. Circulation. 2013;128(22):2422-2446. PMID: 24166575 www.ncbi.nlm.nih.gov/pubmed/24166575.
Kulik A, Ruel M, Jneid H, et al. Secondary prevention after coronary artery bypass graft surgery: a scientific statement from the American Heart Association. Circulation. 2015;131(10):927-964. PMID: 25679302 www.ncbi.nlm.nih.gov/pubmed/25679302.
Morrow DA, de Lemos JA. Stable ischemic heart disease. In: Zipes DP, Libby P, Bonow RO, Mann DL, Tomaselli GF, Braunwald E, eds. Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine. 11th ed. Philadelphia, PA: Elsevier; 2019:chap 61.
Omer S, Cornwell LD, Bakaeen FG. Acquired heart disease: coronary insufficiency. In: Townsend CM Jr, Beauchamp RD, Evers BM, Mattox KL, eds. Sabiston Textbook of Surgery. 20th ed. Philadelphia, PA: Elsevier; 2017:chap 59.
Rehabilitate Your Heart
Help for recovery from heart conditions
Building the chest and back muscles after open heart surgery
Once you have your weight restrictions from bypass surgery lifted (and your physician’s permission) it is time to build back the muscles you lost from surgery.
The muscles are weak from the limited lifting for the last 3 or more months. It is important to go slow and to balance the muscles. In previous posts I write about the importance of posture and stretching after open heart surgery to prevent or manage pain. https://rehabilitateyourheart.wordpress.com/2012/05/21/stretching-your-upper-body-following-open-heart-surgery-12/
The muscles of the chest and back balance one another.
Muscles work like a pulley system, if one group is shortened the other is lengthened. By strengthening the chest muscles the opposing muscles of the back are lengthened. Therefore the back should be worked just as much as the chest to maintain a balance. A common issue is many only train their chest, neglecting the back and this sets the stage for shoulder, neck and back problems down the road. By strengthening both you create a balance to the muscles.
There are many ways one can work the muscles including free weights, dumbbells, resistive bands, or the bodies own resistance – such as push ups. . It is important to start out light. You may have had a 10-20 lb lifting restriction for some time. It is not graduated up but simply lifted. Therefore don’t start with really heavy weights. Work your way up. Start with a few exercises, see how your body feels the next day. You shouldn’t experience days of pain from the first few workouts, you should be able to tell you worked the muscles but not be suffering. Don’t overdo it!
Remember it is approximately one full year of healing following surgery.
The bone is knit together but to rebuild the strength, decrease the inflammation and allowing the nerves to heal it takes a full year. Some precautions to note – if you feel any shifting, cracking or popping of the sternum stop. Try again in a month or two, or modify the movement to avoid the shifting. If you cannot move it without the shifting contact your surgeon.
Breathing with weight training is vital.
Exhale on exertion . This means when you are pushing the weight away from your body breath out. When you are returning the weight to your body breath in. It is extremely important to your heart’s health not to hold your breath. Holding your breath increases the blood pressure, strains the heart, and for some people can make them light-headed or pass out. Not good when you have weights in your hands to pass out! This breathing technique should be used with all of your strenuous physical activities or lifting, pushing, or carrying.
The following images of exercises address the key muscle groups lost from open heart surgery. Start with a light weight – it may be 10 lbs in each hand or it might be 5 lbs, everyone is different but you will appreciate starting with light weights as we expect a little soreness initially. See what works for you. The initial goal is to do many repetitions, gradually build up the amount of weight over time. Try doing each exercise 10 times, if it is easy then next time add a little more weight. If it is difficult, try less weight next time. It is recommended you start with 10-15 repetitions of each exercise, and do it in 1-2 sets the first week or two. You can gradually add in more sets of the 10-15 repetitions. Don’t work the muscles every day, try for 2-3 times per week. The muscles need recovery time.
Chest muscles – note the elbows of the lady in the second picture, this is an example of good technique. Don’t let the elbows come lower than the shoulders as it puts a lot of stress on the the sternum and shoulders, and you don’t want to be hurting the next day. Breathe out as you lift the weight up. Don’t hold your breathe!
Shoulder muscles – note only lift the weights to 90* lifting higher than this tends to irritate the shoulders. Be aware to use your muscles not the swinging of your body for momentum. Lift the weight to a slow count of 1 -2, then lower it even slower a slow count of 1-2-3-4. Remember breath out as you lift the weight up.
These are standing fly’s, the knees are bent to support the lower back’s natural curves and prevent injury.
Back exercises – standing row. This works the muscles between the shoulder blades. When doing exercises bent over remember to come back up gradually, as many heart patients experience dizziness when bent over. Again remember to BREATHE! If you don’t have weights there are resistive bands that can be used. They can be found at your physical therapy centers, medical supply stores or fitness stores. They come in a variety of strengths, remember start light. Make sure you control the band or weight and that it doesn’t control you.
Weight machines are good. Here is an example of working both the chest and the back. I love lat pull downs and seated rows. Typically I will have patients work these for 1-2 weeks before I introduce the chest press, as the back is far more neglected than the chest muscles in our day to day use. Below are ways of doing the upper back using resistive bands.
I know some of you are impatient about getting back to push ups. I generally start patients with push ups against a wall initially, gradually moving feet further back. When through the initial muscle soreness, have good breathing techniques then have them begin floor push ups.