Marquette General Heart Institute
Heart Surgery
Types
of heart surgery:
Coronary
artery bypass graft surgery (CABG) is often necessary to provide an adequate supply of oxygen to the
heart muscle. When a blockage or narrowing of one or more of the
arteries supplying blood and oxygen to the heart muscle, increases
to the point where a person is experiencing symptoms of chest pain,
arm or neck discomfort, shortness of breath, fatigue, treatment
is indicated. Depending on each individual’s disease process,
procedures such as angioplasty or stent placement may first be utilized.
If these procedures are not appropriate or successful in keeping
the vessels open long term, bypass surgery may be scheduled.
Coronary
artery bypass grafts increase the blood supply to the heart muscle
by bypassing the damaged vessels. Bypasses are most often accomplished
by using one of either of the leg veins (saphenous vein), or arteries
from the chest wall (internal mammary arteries). After the bypass
grafting, the blood travels through the grafts delivering blood
and oxygen to the heart muscle.
The type of
graft used is determined by your surgeon and depends on the location
of the blockage, the size of your coronary arteries and the number
of blockages you have. Your body is able to function properly without
the donated arteries and/or veins used for the bypasses.
Traditional
CABG surgery involves the surgeon making an incision down the center
of your chest and your sternum (breastbone). This allows the surgeon
direct access to your heart. During the surgery you will be connected
to the heart lung bypass machine, which circulates blood and oxygen
throughout the body. The heart is stopped during this time, while
the surgeon completes the bypass grafting. After the grafts are
completed, the heart is restarted, the surgeon closes the sternum
with special wires, and the chest incision is closed with sutures
and staples.
Minimally
invasive coronary artery bypass surgery (MIDCAB)
Minimally invasive surgery may be performed on select patients with
one or more blocked coronary arteries. Surgery of this type requires
a smaller incision, and is accomplished without using the heart
lung bypass machine. The surgeon is actually completing the bypass
grafting while the heart is beating. Only the specific portion of
the heart the surgeon is working on is stabilized (held still);
the remainder of the heart continues to pump blood throughout the
body.
Benefits of
minimally invasive surgery may include a smaller incision, a shorter
hospital stay and recovery time, less bleeding, pain and potential
for infection.
Minimally
invasive saphenous vein removal
Previously, removal of the leg vein for bypass grafting often required
an incision from the groin all the way down to the ankle. Now this
may be completed using special instruments and working through several
small incisions. A tiny balloon inserted under the skin gently removes
the vein from surrounding tissue. This enables the surgeon to remove
the vein and close the incision with minimal blood loss and much
less risk of infection. Healing is much quicker, there is much less
scarring and discomfort.
Valve
surgery is sometimes needed to replace or repair damaged or scarred heart
valves. There are four heart valves, which keep the blood flowing
through your heart properly. The heart valves act like one way doors
allowing blood in and out of the heart chambers with each heart
beat. When the heart valves do not function properly, the blood
can backup or leak through the valve, causing an increased workload
on the heart muscle and a weakened heart.
The aortic and mitral
valves are the most common valves requiring corrections. In
aortic valve regurgitation, the aortic valve, the valve
which opens to direct blood flow to the body, doesn’t close
completely. Blood leaks backward into the heart; the heart must
work harder to pump out enough blood to meet the demands of the
entire body. Aortic valve stenosis, means the valve
itself has narrowed and is obstructing the flow of blood out to
the body. Mitral valve regurgitation occurs when
the the valve connecting the left chambers of the heart does not
close properly. This causes blood to flow backwards, again making
the heart work harder to meet the oxygen and blood needs of the
body. In mitral valve stenosis, the valve itself
narrows, obstructing blood flow between the two left chambers of
the heart.
Symptoms of
valvular heart disease include shortness of breath, dizziness, pain,
and other health problems. At times medications can be utilized
to relieve these symptoms; other times the medications fail and
heart surgery becomes necessary. Various causes of valve problems
include birth defects, infection, rheumatic fever, and heart attack.
When a valve needs to be replaced the cardiovascular surgeon will
speak with the patient about the best type for that individual.
The two types are mechanical or tissue valves. Tissue valves originate
from either animals or humans.
Two
other types of heart surgery include atrial defect repair and aneurysm (a ballooning out of an
area of the heart muscle) repair.
Diagnostic
tests
Before heart
surgery, there are several tests that are routinely performed. These
include: an electrocardiogram (ECG), chest x-ray, urinalysis, and
blood tests which include bleeding time, complete blood count, and
blood chemistry. In addition, sometimes breathing tests are ordered
to determine lung function. Cardiac
catherization is performed to accurately visualize and determine
the extent of disease. Other tests that are sometimes ordered are
transesophageal echocardiogram, cardiac ultrasound, Doppler tests
of the legs, and stress tests.
Preoperative
period
The cardiovascular
surgeon and anesthesiologist will examine the patient and discuss
questions or concerns. The night before surgery a sleeping pill
may be ordered to help with rest. After midnight nothing should
be taken by mouth unless specifically ordered by the surgeon or
anesthesiologist. Normally a preventive antibiotic will be administered
prior to the operation.
The nursing staff is an excellent resource for asking questions
and discussing concerns; they will help to make the patient as comfortable
as possible. Remember it is normal to feel anxious before surgery
and the doctor can order medications to relieve some of the anxiety.
It is imperative to let the nursing staff know if there are any
sensations of pain or discomfort immediately.
A respiratory therapist may discuss and give instruction about breathing
exercises that can be carried out before and after surgery. These
breathing exercises are important to avoid complications after the
surgery is accomplished.
A special surgical scrub will be prescribed before the operation
to decrease the amount of bacteria on the surface of the skin. This
special soap can be used to cleanse the chest from neck to pubic
area and legs if it is anticipated that leg veins will be used for
grafting. The shave preparation is usually done in the operating
room at MGH; this may vary at other facilities.
The family will be asked to keep personal possessions not permitted
in the operating room such as: glasses, contact lenses, dentures,
removable bridges, hearing aides, watches, and jewelry. The family
is asked to wait in the ICU waiting lounge and will be updated by
an ICU nurse from time to time as the procedure progresses. The
heart surgery patient is generally sent immediately to the ICU from
their surgical suite.
It is important for the patient and family to ask questions or discuss
concerns with the staff to help dismiss some of the anxiety experienced
by this surgery.
During
heart surgery
Heart surgery
usually lasts about 3-6 hours. During this time, the patient is
anesthetized
( put into a state similar to sleep but also unable to feel pain).
A breathing tube is inserted into the windpipe (trachea) and breathing
is performed by a machine called a ventilator. These devices will
remain until the patient is awake and able to breathe on their own.
In the course of the operation, the patient is often assisted with
a heart-lung machine that circulates the blood while the heart stops
beating for a short period of time. This allows the surgeon to perform
the necessary grafting or repairs to the heart. Many patients and
families find this anxiety producing but the heart-lung machine
is doing the work of the heart while the heart is immobilized. There
is a highly trained health care professional that monitors the patient
and the machine while this occurs.
Because the
breastbone is opened to gain access to the heart, it is necessary
to have chest tubes placed in the chest to allow for drainage and
to help the lungs stay expanded. There will be other devices used
to monitor the vital signs and function of the heart. An arterial
tube is usually placed in the wrist to measure blood pressure continuously
and draw blood samples for lab specimens. A tube called a Swan-Ganz
catheter is placed into the neck area and constantly monitors the
body’s fluid levels and pressures inside the heart.
The patient will have a bladder catheter for the continuous measurement
and collection of urine. A heart monitor is applied to the chest
with sticky patches (electrodes) for the staff to check the heart
rate and rhythm at all times. There will also be a pair of thin
wires coming out of the chest and connected to a temporary pacemaker
to adjust the heart rate if this becomes necessary. IV’s will
be in place to assist with fluid balance and to receive medications
during the surgery and after until the patient is able to take food
and liquids by mouth again.
After
surgery
After surgery
the patient is brought
to their ICU room, the nurse will be in attendance almost continuously
for the first few hours. After the patient gets settled, which takes
about an hour. The family can usually visit for a period. The person
may appear swollen, pale, and cold, perhaps even shivering. Slowly
the patient will start to awaken.
One of the first things that the person will be aware of is the
breathing tube; it may feel like there is an inability to breath
or the sensation of breathing ‘through a straw”. It
is best to try to relax and allow the breathing machine to do its
job. This tube will be removed when the patient is fully awake and
able to breath on their own effectively.
There may be pain in the chest from the incision or leg pain if
grafts have been taken from them. Initially, the nurse will ask
about the presence of pain and give pain medications judiciously.
Later in the recovery process, it is important for the patient to
request pain medication themselves.
Pain management is essential to the recovery process; it will allow
increased movement and facilitate coughing and deep breathing. Pain
medication works more effectively if there is not a delay in requesting
it or waiting too long.
Generally, the patient is assisted out of bed to a chair within
the first 24 hours after surgery. This may sound painful, even cruel,
but the staff is there to help with movement and pain management.
Getting out of bed and moving is imperative to the recovery process
and to regain strength. Remember the goal is to return to some of
the normal activities of daily living as soon as possible without
overdoing activity. The nurse and physical therapist can assist
with the rest-activity process.
Many times the heart surgery patient will not have much of an appetite
for a time after the operation. Nutrition is also important for
the healing process to occur; the diet is usually quite liberal
for the first few days. In the beginning, ice chips and clear fluids
will be offered. When the patient can tolerate these items without
becoming nauseated the diet will be advanced.
Within 24-48 hours most patients are ready to be transferred to
a less acute nursing unit. This can feel a little intimidating but
it means that the recovery process is progressing well. The family
can be very helpful during this period by assisting with activities
of daily living, such as, bathing, walking, and remembering to continue
breathing exercises. The family’s involvement can increase
comfort level as the discharge date approaches.
Going
Home
At the time
of discharge, there will specific written instructions regarding
activity, diet, medications, and follow up appointments with the
doctors. It is normal to feel anxious about going home; some people
even feel depressed after heart surgery. Emotions should return
to usual in about 4 to 6 weeks postop.
Most patients are able to return home in a private automobile. Remember
to use the shoulder harness or seatbelt; a small pillow between
the chest area and the safety device can increase comfort. If there
is a long distance to travel, it is important to get out of the
vehicle to walk around every hour or two. This helps the circulation
to the legs and can reduce swelling.
The recovery process takes about 4 to 6 weeks. It is crucial to
increase activity gradually- doing a little more each day without
overdoing. Periods of rest during the day will assist in the recovery.
The incision initially will appear purplish becoming
pinkish and then flesh color. The amount of scarring depends on
the person’s skin type and how the wound initially heals.
While showering at home, the incisions should be gently cleansed
with soap and water. A dressing can be used to protect clothing
from drainage, however, in the absence of drainage the incisions
can be left open to air.
The sternum (breastbone) may have been cut during
the surgery; most activities will be limited protecting this area.
It requires 4 to 6 weeks for this bone to heal completely; the sternum
is wired back together during surgery and need not be removed. The
wires may show up on a chest x-ray as white lines.
Diet: Many times after heart surgery there is a
loss of appetite; this will return as recovery progresses. Eating
a well balanced diet will increase strength and aid with healing.
The doctor will prescribe a heart healthy diet which is low in sodium,
fat, sugar, and cholesterol. The doctor can also make suggestions
about the amount of alcohol, if any, that is permissible.
Driving is not an acceptable activity for about
4-6 weeks after discharge from the hospital since the sternum (breastbone)
is still mending. An accident even while using a safety belt or
shoulder harness may not avoid an impact between the healing chest
and the steering wheel. This unfortunate event could reinjure the
sternum and would definitely be painful. Long trips should be delayed
until after the first physician follow-up appointment. When riding
in a car, it is important to take a break every 1-2 hours and walk
around. This can help avoid swelling and increase blood flow to
the legs.
Exercise and activity will be suggested by the
doctor. Remember to exercise when feeling well rested and progress
slowly but surely. Sometimes the doctor will refer the patient to
a cardiac rehabilitation program.
Medications will be prescribed by the surgeon at
the time of discharge from the hospital.
Some patients had been taking medications prior to surgery; it is
important to compare the previous medication regime with the discharge
medications to avoid potential errors or overdoses. The nurse can
assist with this at the time of discharge. Normally pain medication
is also prescribed to help with post surgical discomfort.
Quit
Smoking: This is a good time to” kick the habit”
While in the hospital smoking is not permitted giving the patient
a head start on smoking cessation. This is a good time to “kick
the habit”. Smoking can increase be possibility of complications
after surgery and the potential for further circulation and lung
problems.
Support hose will improve the blood flow to the
legs; it is desirable to continue to wear them for the first weeks
of recovery. The stockings should be taken off for periods during
the day. As activity returns to normal, the need to wear the hose
will decrease until they can be discontinued.
Returning to work should be discussed with the
doctor. Generally, a period of 4-6 weeks is required but that also
depends on type of work and the individual’s recovery progress.
When
to call the doctor
 |
Swelling,
redness, pain, or drainage from incision sites need to be reported
to the surgeon; although, a small amount of clear to pinkish
drainage is common. Any drainage from the chest wound should
be investigated. |
|
Chest pain,
shortness of breath, or return of presurgical angina symptoms |
|
Pain in
the neck, shoulders, or chest that increases with a deep breathe
can be a symptom of pericarditis (an inflammation of the sac
around the heart). |
|
Fever of
101 degrees for 24 hours or longer |
|
Flu-like
symptoms |
|
Extreme
fatigue lasting more than 3 days |
|
Weight
gain of 2-3 pounds over 2 to 3 days |
|
Slow, fast
or irregular heartbeat |
|
Severe
bruising for no apparent reason |
|
Any other
concerns or questions |
