HEART BYPASS SURGERY

Coronary Artery Disease

Coronary artery disease is the narrowing of arteries that supply oxygen-rich blood to your heart. When your heart is deprived of oxygen, you may experience angina (chest pain from heart muscle "cramping") or a heart attack. These symptoms are caused by atherosclerosis ("hardening of the arteries"), a condition often accelerated by certain risk factors in your lifestyle. For thousands of people each year, bypass surgery can successfully relieve the symptoms of coronary artery disease.

Angina
Angina is a warning sign for coronary artery disease, felt as chest pain or pressure (often radiating to your neck or upper arm) and a shortness of breath. Angina may last only a few minutes and often follows exercise, exertion or emotional stress.

Atherosclerosis
Atherosclerosis is the gradual build-up of fatty tissue (plaque) in your blood vessels. When a coronary artery is blocked, any increase in heart activity (exercise or exertion) puts a greater demand for oxygen on your heart's already limited supply. Angina, heart attack or death can result. Bypass surgery detours the blockages to carry oxygen-rich blood to your heart.

Risk Factors
You can control many of the risk factors for coronary artery disease, such as smoking, high blood pressure, a high-fat diet and lack of exercise. Other risk factors are age, sex, diabetes and a family history of heart disease.

Coronary Bypass Surgery

Coronary artery bypass surgery, the most frequently performed heart operation today, is a time-tested, highly successful procedure, thanks to medical advances and technological breakthroughs in open heart surgery. There are many reasons why bypass surgery may be recommended, but in every case, the goal of surgery is the same: to detour your blocked coronary arteries to supply more oxygen to your heart muscle.

Reasons for Surgery
Your coronary arteries are as unique as your fingerprint. Before recommending surgery, your doctor carefully evaluates your cardiac health and diagnoses your particular heart problem. Surgery may then be recommended for a variety of reasons: if medications no longer relieve your angina, if you have a life-threatening coronary blockage or if you have complications following a heart attack.

Bypass Goals
The goal of your surgery is to bypass each narrowed artery with a healthy vessel from your leg or chest wall. Each bypass increases the oxygen supply to your heart muscle and helps relieve your chest pain and other symptoms. You may need several bypasses, depending on the number of blockages you have and the amount of heart muscle affected.

Bypass Technology
The development of the heart-lung machine made open heart surgery possible. During surgery, your blood is circulated through the heart-lung machine, where it receives oxygen and is pumped back through the body. Today's computerised heart monitors and new cardiac medications help make your bypass surgery a reliable procedure.

Normal Coronary Arteries

To understand bypass surgery, it helps to have a basic understanding of your heart as a working muscle, and its blood supply, the coronary arteries. Your heart is a muscular pump that requires its own constant supply of blood. The right and left coronary arteries, and the smaller arteries that branch off from them, take blood from you aorta to nourish specific areas of your heart.

The right coronary artery branches off from your aorta and nourishes the right side and bottom of your heart.
The left main coronary artery branches into two arteries and nourishes the greatest amount of heart muscle (which is why a blockage in this artery can be life-threatening). The left anterior descending coronary artery nourishes the front of your heart, including your heart's main pump, the left ventricle. The circumflex coronary artery nourishes the back of your heart.
Your heart's main pump is the left ventricle. The left ventricle pumps blood through the aorta, the large blood vessel that carries oxygen-rich blood to your coronary arteries and the rest of your body.
The internal mammary artery lies in your chest wall and may be used to bypass a blocked coronary artery.

Cardiac Catheterisation

Cardiac catheterisation, part of every bypass patient's evaluation before surgery, helps your doctor plan the number and location of the bypasses you need. Cardiac catheterisation is simply the insertion of a catheter (a thin, flexible tube) into your heart to provide your doctor with a "roadmap" of your coronary arteries and a picture of your heart's pumping action.

Your Lab Experience
Cardiac catheterisation is performed in a large lab by your doctor and skilled technicians. Your doctor inserts a catheter into a blood vessel in your arm or groin, and uses a special x-ray screen to guide the catheter into your heart. A dye is then released, and x-rays are taken to reveal your heart's blood flow. Since your co-operation may be needed during the procedure, a local anaesthetic is usually used, along with a mild sedative to help you relax. An overnight hospital stay may be needed.

Your Angiogram
Your angiogram provides your doctor with a "roadmap" of the blood flow through your coronary arteries. Dye is released at the openings of the right and left coronary arteries and flows throughout your arterial "tree". The x-ray results reveal how many blockages you have, where they are, and how much blood flow is being blocked in each artery.

Your Left Ventriculogram
Your left ventriculogram provides your doctor with a picture of the pumping action of your left ventricle. Dye is released into your left ventricle to outline the chamber as it pumps. The x-ray results reveal the size of your left ventricle, faulty pumping motion of your heart muscle, a leak in the wall of your heart or faulty heart valves.

Understanding the risks. Although complications of cardiac catheterisation are uncommon, your doctor will discuss the potential risks with you and answer any questions you have before the tests are done. A standard consent form is provided for you to sign before your cardiac catheterisation.

Preparing for Surgery

Your cardiac care begins as soon as you are admitted to the hospital. A patient educator or nurse is available throughout your hospital stay to talk with you and your family about your hospital experience. Other preparation for surgery includes a history and physical exam by your doctor, a visit from your anaesthesiologist to explain your anaesthesia and routine lab tests.

Information and Support
A patient educator or nurse who specialises in caring for heart surgery patients can help explain the surgery experience to you and your family, discuss your recovery in the hospital and at home, and answer any questions you or your family may have.


The Night Before Surgery
Your anaesthesiologist takes a brief medical history and explains your anaesthesia to you. You'll be given a normal dinner, but you cannot eat or drink anything after midnight (surgery will be cancelled if you do). To help prevent infection after surgery, your chest, legs and groin are shaved, and you're asked to shower before going to bed.

The Morning of Surgery
Before going into surgery, you're weighed to help your doctor know if you're retaining fluid after surgery. You may be given a mild sedative to help you relax, and you are taken to the operating room on a gurney for your safety. Your family or other support people are directed to a waiting area and will be kept informed of the progress of your surgery.

Understanding the risks. Before you undergo bypass surgery, your doctor will discuss your surgery and its potential risks with you, such as lung complications, post-operative bleeding, heart attack or stroke. A standard consent form is provided for you to sign before surgery.

Your Bypass Surgery

Bypass surgery is performed by a highly skilled cardiac surgery team. During surgery, the heart-lung machine takes over for your heart and lungs, allowing your cardiac surgeon to graft a bypass vessel around each coronary blockage. Surgery can last from two to six hours, depending on the number of bypasses you need.

Your surgical team, led by your cardiac surgeon, includes two assistant surgeons, your anaesthesiologist, a perfusionist (who operates the heart-lung machine) and several cardiac nurses. These specialists are aided by advanced monitoring technology to help assure the safest possible surgery.

Bypass incisions. An incision is made down your chest, and your breastbone is divided to allow access to your heart. If your surgeon will be using a leg vein to make a bypass graft, you'll have a second incision on your leg.

Bypass vessels. The long saphenous vein in your leg can be used to make several bypasses, if needed. The internal mammary artery, which lies in your chest wall, may also be used as a graft. Both are "excess" blood vessels your body does not need.

Bypass grafting. Grafting is performed under magnification with sutures as fine as hair. Each graft is sewn to the aorta (the internal mammary artery already originates from a branch of the aorta). The other end is sewn to the artery below the blockage.

Your ICU Recovery

After surgery, you are transferred to the Intensive Care Unit (ICU) where your cardiac care team constantly monitors your recovery. You may spend a few days in the ICU, although everyone recovers from surgery at a different rate. In the ICU, the tubes used during surgery are removed, and respiratory therapy is begun to help prevent possible lung complications.

Removing Your Tubes
Each of your surgical tubes plays a specific role in your recovery and is removed by the time you leave the ICU. Pain medications are available to help relieve any discomfort. Your surgical tubes may include:

A breathing tube to help you breathe until you are fully awake and breathing normally;
A stomach tube to suction natural stomach secretions;
A bladder catheter to empty your bladder and measure your urinary output;
Intravenous (IV) lines to provide medications, fluids and nutrition;
An arterial line to measure arterial pressure; and
Chest tubes to drain your chest cavity of normal post-operative bleeding.

An EKG monitor records your heart rhythm throughout your ICU recovery. Later on in your hospital stay, you may wear a portable heart monitor the size of a transistor radio.

Respiratory Therapy
Respiratory therapy helps prevent post-operative lung complications such as a collapsed lung, infection or pneumonia. Every few hours, a nurse or therapist helps you with coughing and deep breathing exercises. Hugging a pillow while you cough helps to "splint" and protect your breastbone. Chest percussion may also be performed every few hours. This gentle clapping on your back helps loosen post-operative lung secretions.

Leaving the ICU
Leaving the ICU marks a major step in your recovery from surgery. Your doctor releases you from the ICU when you no longer need its constant, intensive monitoring, a positive move that means you're progressing well in your recovery. From the ICU, you're moved to a transitional or intermediate care unit.

Transitional Care

From the time you leave the ICU until you leave the hospital, your cardiac care team continues to monitor and support your recovery. During your transitional care, you're encouraged to take a more active role in your recovery. Your doctor may recommend that you take part in several types of specialised cardiac care to help you prepare for going home and returning to a normal lifestyle.

Physical Therapy
Through physical therapy, you'll gradually increase your walking and other activity to help all of your body functions return to normal. You'll also learn how to take your pulse and how to limit your upper arm movement to allow safe breastbone healing.

Respiratory Therapy
Respiratory therapy is continued to help prevent lung complications after surgery. You may be asked to inhale or exhale into a spirometer, a device to expand and exercise your lungs. Coughing and deep breathing exercises are discontinued as your lungs return to normal.

Diet Counselling
Diet counselling helps you plan for low-fat and low-cholesterol meals once you get home. You may be given specific lists of foods to avoid, as well as low-fat cooking tips. For some people, a low-salt diet may also be recommended.

Occupational Therapy
Occupational therapy helps you prepare for going home and returning to your daily activities without overtiring. You may learn how to conserve your energy during simple tasks (such as sitting at the sink to do dishes) and how to get out of bed without straining your chest.

Going Home
Once your hospital recovery is complete, your doctor discharges you and your nurse and family can help with your arrangements for going home. You're sent home with the medications you need, and are given any necessary instructions for your safe recovery at home. Feel free to ask any questions you have before leaving the hospital.

Your Home Recovery

The key to a successful home recovery is moderation, especially with your activity. Plan for plenty of time to relax as you begin returning to your normal activities. The following general guidelines and your doctor's specific instructions can help your home recovery to be a safe, relaxing time for you.

While everyone recovers at a different rate, most people can expect a home recovery of 6-8 weeks. During this time, your doctor or nurse can help with any questions that arise.

Activity
Gradually increasing your activity at home helps promote healing and rebuilds your body's muscle tone. Light activity, such as a short walk outdoors, is an excellent way to speed your recovery, but don't overdo it. Be sure to slow down or stop when you feel tired, and alternate your activity with rest.

Alcohol
Most people can safely return to a moderate use of alcohol (1-2 drinks a day). However, you should not drink while you're taking pain medications, tranquillisers, sleeping pills or anticoagulants (alcohol intensifies their effect). Check with your doctor about mixing alcohol with other medications you're taking.

Bathing
It's a good idea to have someone nearby the first few times you bathe or shower, since you may feel light-headed or dizzy. After bypass surgery, avoid extremely hot water (it can interfere with your circulation).

Children
During your recovery, try to show your affection for children in quiet ways: reading together, talking, doing puzzles and taking short walks. Avoid rough games and picking children up until you've healed (it can interfere with breastbone healing).

Driving
Since it takes 4-6 weeks for your breastbone to heal, let others drive during this time (arm motion from steering can intensify your chest pain). Your medications may also make you drowsy and slow your driving reflexes.

Emotions
Talking about your feelings with your friends and family can help release the normal emotional ups and downs after surgery. It's common to feel tired, irritable, anxious or simply not quite yourself for a few weeks. As your recovery progresses, these feelings usually disappear.

Follow-up
Follow-up visits with your doctor help assure that you are recovering safely after surgery. Follow-up tests, such as a chest x-ray to assess your healing or an EKG to assess your heart rhythm, may be performed.

Housework
To limit strain on your breastbone, avoid mowing the lawn, mopping, vacuuming and any activity that strains your chest and upper arms. For the first few weeks, you'll probably just want to rest anyway. Then it's safe to start with light housework, such as setting the table, dusting and light household repairs.

Incisions
You can keep your incisions clean by washing them gently in your daily bath or shower. If you find excess swelling, redness, oozing or tenderness, call your doctor. Avoid skin lotions, which can increase your chance of infection.

Lifting
Try to avoid lifting anything weighing more than two to five kilograms, such as a grocery bag, suitcase or briefcase. Anything that creates force in your chest or upper arms can interfere with breastbone healing while you recover.

Pain
You may have discomfort in your breastbone as it heals, and muscular pain in your back, neck or shoulders. Pain medications prescribed by your doctor can help minimise pain and allow you to be active and safely progress in your recovery.
Regularity
Regularity is a common problem after surgery, a normal reaction to having anaesthesia and being less active for several weeks. If needed, ask your doctor for a mild laxative. Increasing your daily activity and eating more fresh fruits, vegetables and other high-fibre foods also helps.

Rest
You'll need plenty of rest to recover from surgery and feel your best. Plan on at least two rests during the day (more if you feel tired), and alternate activity with time to relax. Insomnia is a common problem and may last a month or two. In the meantime, the medications prescribed by your doctor can help you get a good night's sleep.

Return to Work
Your doctor can advise you when to return to work at your first follow-up visit. People with desk jobs often return in 6-8 weeks; it may be longer for more physical work.

Sex
Rest assured that sex won't interfere with your healing, although you may feel more comfortable sharing your affection in non-sexual ways - dancing, going out to dinner or just being close - for the first few weeks after surgery. Talking about your feelings with your partner can help you both feel at ease. When you feel ready for intercourse, any position is fine as long as it's comfortable, relaxing and allows for easy breathing.

Support Hose
Support hose may be recommended for your first few weeks at home to help prevent circulation problems and swelling in your legs. Putting talcum powder on your legs helps your hose slide on more easily. Smooth out any wrinkles to avoid pressure spots.

Visitors
Support from your family and friends can help you feel better, but you need rest and relaxation, too. Feel free to ask your visitors to leave, or excuse yourself, when you begin to feel tired. During the first few weeks, two visits a day is usually plenty.

Warning Signs
Call your doctor if you have a fever of 38.3ºC or above, an abnormal pulse rate, chills, sweating, shortness of breath, abnormal pain or other symptoms unrelieved by your medications. In general, it's better to call your doctor or nurse with a question than worry about it alone.

Weight
You may be asked to weigh yourself the first thing every morning to determine if you're retaining fluid after surgery. Call your doctor if you gain more than 1.5 kilograms in one day.

Your Cardiac Care Team
During your home recovery, members of your cardiac care team are available to answer your questions. Feel free to call with any questions that may arise. Your surgeon, cardiologist and nurses are concerned with your health and can provide information and support as you recover at home.

Zest
Recovering your former zest may take some time. But take heart: it will happen. You'll feel like yourself before long. Open heart surgery is a unique physical personal challenge. When your sense of well-being and enjoyment in life return, you'll know you've successfully recovered.

Reducing Your Risk Factors

Bypass surgery can treat the symptoms of atherosclerosis, but there is no known cure for the disease itself. There are, however, specific things you can do to help slow the disease process. Along with the guidelines below, your doctor or nurse may give you specific instructions and resources to help you reduce your risk of developing further coronary artery disease in the future.

Quit Smoking
The single best thing you can do is quit smoking. Smoking reduces the amount of oxygen in your blood, increases your body's demand for oxygen and damages the walls of your arteries. It's never too late to stop smoking, either by gradually eliminating cigarettes or by stopping all at once. Setting a date to quit and getting support from your friends and family can help you kick the habit for good.

Blood Pressure Control
Having your blood pressure checked every six months is the first step in blood pressure control. High blood pressure (excess force in your arteries) can put added strain on your heart and speed the process of atherosclerosis. If you're on medications for high blood pressure, be sure to take them as directed. A low-salt diet, exercise and relaxation techniques can also help control your blood pressure.

Less Fat and Cholesterol
A low-fat, low-cholesterol diet may help prevent the build-up of cholesterol (a fatty, wax-like substance) in your arteries, which can restrict blood flow to your heart. Try to avoid saturated fats such as butter, dairy products and fatty meats; instead use polyunsaturated fats such as safflower and liquid corn oils. Limiting fats to two tablespoons a day and eating fewer high-cholesterol foods (eggs, red meat, whole milk) may also be advised.

Regular Exercise
Regular exercise can strengthen your heart muscle and boost its ability to use oxygen. Jogging, brisk walking, swimming and bicycling are all excellent ways to exercise. Your exercise programme should start slowly, progress gradually - and be fun. After heart surgery, an exercise programme should only be started with your doctor's supervision.

Taking Your Medications

Medications are usually needed after bypass surgery to help ensure your future cardiac health. Your doctor may prescribe medications to relieve pain, help you sleep, promote your heart's pumping action and lessen its workload. The tips below can help you take your medications safely.

Medication Tips
Keep a list of your medications and include the name, dose, purpose, special instructions and possible side effects.
Take your exact dose as directed.
Let your doctor know if you experience unusual symptoms after taking your medications, such as an upset stomach, vomiting, diarrhoea or skin rash.
Ask your doctor before taking over-the-counter medications; they can interfere with your prescribed medications.
Keep all your medications in their original, labelled containers, and keep them in a cool, dark place (sunlight can ruin their potency).
Plan ahead for vacations to be sure you have an extra supply of your medications.

After Surgery
You're likely to experience a dramatic relief of angina and a safe return to your normal activities within three to six months. But your full recovery - and your future health - depends on you. You've already met the challenge of open heart surgery. Your new challenge is to begin living in a way that reduces your risk of further coronary artery disease. With a healthy lifestyle, you'll not only recover more safely, you'll also help yourself reach your best possible health for the future.

Your Cardiac Care Team

If coronary artery bypass has been recommended to treat your heart problem, you're not alone. Throughout your surgery experience, you have the support of your cardiac surgeon, cardiologist, cardiac care nurses and other cardiac specialists. Aided by state-of-the-art medical technology, your cardiac care team works together to provide you with the highest quality medical care not only in the hospital, but after your surgery, as you recover at home.

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