TYPES OF HEART BYPASS SURGERY

Off-pump coronary artery bypass surgery

When the heart is allowed to continue to function during coronary artery bypass surgery there is no need to use a cardiopulmonary bypass machine although one is always on standby should certain complications arise.

As the coronary arteries are situated on the outside of the heart, off-pump coronary artery surgeries are associated with less risk than off-pump heart valve procedures. This does not mean that off-pump is the better option as multiple factors will contribute to your surgeon’s advice concerning the most effective procedure. Furthermore, the continuous pumping of the heart means it is much more difficult to sew the tiny stitches that attach the ends of the graft vessel above and below the area of coronary atherosclerosis. Off-pump procedures, even without the patient needing to go on and come off the heart-lung machine, are not always the quicker option. This means that if you need more than 2 grafts, on-pump surgery is the only option. Recovery times after successful surgery, however, can be significantly shorter.

Minimally invasive direct coronary artery bypass (MIDCAB)

During MI coronary artery bypass surgery, one lung must remain flat. This is achieved through a special breathing tube that can close off one lung but allows the other to function under the support of a ventilator or breathing machine. For this reason, not everyone is able to undergo this type of operation as only half of the lung capacity is available. If you are already experiencing shortness of breath when relaxed or if you have not yet stopped smoking, this may not be the right surgery for you. Other options can be discussed with your chosen specialist

Access to the heart during minimally invasive valve surgery is obtained through a 7 to 10 cm incision between2 ribs (intercostal space), usually in combination with small 2 cm incisions for video- or robotic-assisted cameras and instruments that are also used to remove the LIMA or RIMA vessel. The side of the incision depends on which coronary arteries need treatment but is nearly always the left-hand side

Preparation includes 1 or 2 intravenous catheters, a central venous catheter and an arterial catheter. After the administration of a general anaesthetic the special breathing tube is placed into the airway as well as the probe of a transoesophageal echocardiogram machine. Even where cameras are used, ultrasound gives an overall view of the inside of the heart as the surgeon works and helps to guide the many cannulas that must be used. A urinary catheter is inserted after you are asleep and special sensors that measure oxygen levels in the brain are stuck to your forehead.

The chest area is disinfected and sterile drapes placed to cover your body, leaving only a portion of the chest visible. If you prefer a single-sex surgical team, Remedazo can arrange this request.

After the mammary bypass graft is removed from the inside of the chest wall, a device is placed on the heart to limit its movement. This can cause the heart to function less efficiently. Part of the sac surrounding the heart – the pericardium – is opened and the surgeon finds the area that requires treatment. The affected section of the coronary artery is opened and a shunt is inserted. A shunt is a device that keeps the to-be-operated section of artery free of blood without overly disturbing blood flow. The alternative is to temporarily clamp the artery ends closed with no blood supply to the portion of heart muscle it serves – this is a technique that may be used in healthier individuals. The shunt is approximately the same form as a Q-tip or dumbbell; both ends seal off either side of the artery, but a hollow tube connects them. This provides a conduit through which blood can continue to travel as the surgeon stiches the top end of the graft to the side of the affected coronary artery (end-to-side anastomosis). A special misting apparatus is used throughout this part of the surgery which fills the treated vessels with saline and eliminates air from both the graft vessel and the bypassed, shunted coronary artery. The lower end of the graft vessel is then stitched in place under the area of blockage. The mister continues to work as the shunt is removed; there is a very low risk of air embolism in MIDCAB surgery.  When necessary your surgeon may place stents in the treated artery or in other regions that can be accessed through the small incision. The sac around your heart and the incision in your chest are then closed.

All minimally invasive coronary bypass surgery involves a thoracic drain that removes fluids from the operation site. Fluid can create pressure on the heart or become infected. 

This technique needs a very experienced, well-trained surgeon as there is little space to work. Minimally invasive surgery requires less recovery than both total sternotomy and minimally invasive on-pump surgeries as well as fewer complications and less postoperative pain.

After your surgery you will remain asleep while your anaesthesia team transports you to the intensive care unit (ICU). You will be woken within the hour, often immediately after you have been put in your bed and connected the ICU vital sign monitoring system. Pain medication will have been administered beforehand and you will remain comfortable. 

The average intensive care department stay after MIDCAB is 24 hours. You should be able to get out of bed by this time. Before you are brought to a surgical ward the chest drain and urinary catheter will be removed.

You will stay in hospital for a further 2 to 4 nights. You may be prescribed anticoagulant medication that must be taken as instructed. Around 48 hours after your arrival on the surgical ward the arterial catheter will be taken out of your wrist. The central venous catheter will be removed the same day. Your intravenous catheter is removed when you no longer require strong pain medication.

After your surgeon is satisfied with your progress you will be transported home with written instructions in your language of choice. Trained nursing staff is provided, as is help with meals and transportation to all follow-ups. 

It is possible to fly home the day after discharge from the hospital; however, your surgeon may need to fill in a form for your airline which we will arrange. It is also advised not to travel alone – you will not be able to carry heavy luggage. If necessary, we can provide medically-trained personnel to accompany you. Full recovery from a successful MIDCAB requires 2 to 4 weeks. You can return to your usual daily activities within the month if they do not involve high levels or stress or exertion.

Robot-assisted coronary artery bypass (RACAB) 

Robotic-assisted off-pump surgeries require up to 5 small incisions in addition to the minithoracotomy incision and is able to bypass more than 2 points of stenosis in a single procedure. The robot arms, controlled by the cardiothoracic surgeon at a distance, removes the mammary artery. This means that the largest incision in this surgery is less that 7 cm in length. The rest of the operation is performed in the same way as the MIDCAB. The smaller incision and minimal pushing of the ribcage to manually retrieve the graft artery means less postoperative pain. Hospital stays and aftercare are otherwise similar to MIDCAB.

When the entire operation is carried out using the robot, the procedure is known as total endoscopic coronary artery bypass or TECAB. Hospital stays are reduced to 1 to 3 days when surgery is successful. 

Off-pump coronary artery bypass surgery (OPCAB)

In OPCAB surgery, a vertical incision is made along the length of the sternum as with on-pump procedures. This is a much larger incision than minimally invasive types but has the benefit of increased surgical access and more grafts can be achieved. 

Again, grafting technique is the same as in the minimally invasive procedure described above. The most important difference is the size of the incision and the need to place permanent sternum wires to bring the open ends of the breast bone together. These are made of lightweight titanium and will not cause metal detector alarms to go off.

OPCAB is associated with a higher need for physiotherapy to help with breathing techniques than minimally invasive techniques. 

However, OPCAB is an off-pump procedure that does not require cardiopulmonary bypass, even though all off-pump procedures have such a machine on standby should this become necessary. The chance is slight that an off-pump surgery is converted to an on-pump procedure – perhaps in 5% of cases. The avoidance of cardiopulmonary bypass means the risk of postoperative infection, stroke and atrial fibrillation (an irregular heart beat that can cause blood clots) is much lower

Even though OPCAB does not use cardiopulmonary bypass the hospital stay is only a little less than on-pump open sternotomy CABG – 4 to 8 days instead of 7 to 9. The risk of damage to the heart muscle is less but the amount of blood supplied by the graft tissue can be less than grafts placed during on-pump procedures. With all types of heart surgery, each has its advantages and disadvantages that have differing balancing powers according to surgical skill, quality of materials and equipment, hospital hygiene, nursing staff knowledge and, of course, your state of health, expectations, age, gender and expectations. By way of 3 free Second Opinions, you can speak directly with experienced cardiothoracic surgeons to find out which surgery or surgeries are the most likely to produce the best personal outcome.

All off-pump, minimally invasive and robot-assisted coronary artery surgeries need specialist training and the opportunity to perform the technique as regularly as possible. Remedazo can put you in touch with a limited number of extremely specialised cardiothoracic surgeons who have trained in and performed OPCAB, MIDCAB, RACAB and TECAB surgeries all over the globe.

On-pump coronary artery bypass surgery

Individuals may be advised to undergo an on-pump procedure for various reasons. While cardiopulmonary bypass (CPB) has many side effects and requires longer recovery times, the manipulation of a beating heart without CPB can create substantially low blood pressure, impaired blood supply and arrhythmias; there is risk of permanent damage to the brain, kidneys and lungs. This is the primary reason why off-pump procedures are sometimes converted to on-pump surgeries. It may also be possible that you need more than 2 grafts and your local hospital does not employ specialists in robotic-assisted off-pump techniques. Furthermore, both multiple grafts and multiple valves can be treated when no blood flows through the heart. In these cases, if you are considered healthy enough, an on-pump procedure via total sternotomy (traditional CABG) or with smaller incisions (PACAB) may be advised. 

On-pump open sternotomy coronary artery bypass graft (CABG)

Preparation includes 1 or 2 intravenous catheters, a central venous catheter and an arterial catheter. After the administration of a general anaesthetic, an endotracheal tube is placed into the airway as well as the probe of a transoesophageal ultrasound device. A urinary catheter is inserted after you are asleep and special sensors that measure oxygen levels in the brain are stuck to your forehead.

The chest is disinfected and sterile drapes are placed to cover your body, leaving only the disinfected areas visible. If you prefer a single-sex surgical team, Remedazo may be able to arrange this request.

The surgeon cuts vertically through the sternum, muscle and membranes of the chest wall. The LIMA, RIMA or both are removed. If another artery or vein is to be used as a bypass graft, an experienced vascular surgeon will assist while the cardiothoracic surgeon opens the chest. Preparation is made for the attachment of cannulas that bring blood into the heart-lung machine and back into the body. Two venous cannulas need to be inserted into each of the vena cava veins and connected to form a single tube in the right atrium. Your surgeon may opt to insert a catheter via the groin instead. The arterial cannula must be inserted into the aorta at the top of the heart. In a minority of cases this is achieved via the femoral artery at the groin. When the surgeon is confident that the sites of cannula attachment are not damaged he or she makes special stitches around the aorta. With the cardiopulmonary bypass machine ready, a small incision is made in this major artery, the cannula is inserted and the stitches around it quickly pulled so that there are no gaps or leaks. The arterial cannula is then attached to the bypass machine. With much less pressure in the left side of the heart, the venous cannula can be placed and attached without these special stitches. 

The heart-lung machine, now connected to both cannulas, takes over the role of the heart, keeping the blood at the right temperature, filtering it, and oxygenating and feeding the body tissues during the operation. The heart is stopped with medication. During the surgery you will be cooled down. This is to protect your brain and other organs by reducing their need for oxygen and energy.

The surgeon then has unhindered access to all coronary arteries. With the blood bypassing the heart, manipulation does not cause serious side effects and coronary arteries behind the heart can be more safely accessed. In fact, open surgery is much more straightforward than other methods but the inclusion of cardiopulmonary bypass and the larger incision create increased postoperative risks of pain, breathing problems, cardiopulmonary bypass drug reaction and a usually temporary state of attention disorder after waking known as postperfusion syndrome. The longer the time on a heart and lung bypass machine, the higher the risks. The incision in the heart is then closed and pacing wires are placed within the thorax wall. When this has been done the heart is restarted using defibrillator paddles applied directly to the heart muscle. Ultrasound checks the function of the new or repaired valve(s). When satisfied, the surgeon closes the chest. As the bone of the centre of the chest has been sawn through, lengths of wire need to be twisted to pull the two edges of bone closed. These titanium wires do not need to be removed and will not set of metal detector alarms.

The cardiopulmonary bypass machine then rewarms your blood to body temperature as the surgeon makes sure no air is left in the heart. When he or she is satisfied, the heart-lung machine is disconnected from the cannulas and they are removed. Cannula incisions are sewn closed. Heart function is then restored. 

Open heart bypass surgery requires the placement of thoracic drains to remove fluids from the operating site. Fluid can create pressure on the heart or become infected. In combination with incisions through the skin and muscle, an increased need for pain control and a full general anaesthetic, this means a longer hospital stay and recovery than with transcatheter surgery. 

After your surgery you will not be woken up straight away but brought to the intensive care department under general anaesthetic. After approximately 4 to 6 hours the decision will be made by the intensive care physician to gently wake you and take out your breathing tube. You may drink sips of water after a further 4 hours and will be offered a light meal within 8 hours of waking. Pain is controlled with intravenous medication. You will remain in the intensive care department for 1 to 3 nights under careful monitoring. A physiotherapist will visit at regular intervals to help you with breathing exercises and teach you how to sit up and get out of bed. You should be able to get out of bed within 48 hours of being woken from the general anaesthetic.

Upon arrival at the cardiology department, your urinary catheter will be removed. Intravenous and arterial catheters are usually left in place. If your heart does not show any signs of arrhythmia (irregular heartbeat), the pacing wires placed on the outside of the heart will be removed. This is an unpleasant sensation but not associated with pain. Your surgeon will make regular visits and prescribe anticoagulant medication that must be taken as instructed. Over the next 24 hours, the arterial catheter will be taken out of your wrist.

Open heart bypass surgery involves a 7 to 10 night hospital stay depending on your preoperative symptoms and surgical results. The intravenous catheter is removed 24 to 48 hours before discharge. 

You will be transported home after your surgeon is satisfied with your progress with written instructions in your language of choice. Trained nursing staff is provided, as is help with meals and transportation to all follow-ups. 

It is possible to fly home 10 days after your operation; however, your surgeon may need to fill in a form for your airline which we will arrange. It is also advised not to travel alone. If necessary, we can provide medically-trained personnel to accompany you. Full recovery from a successful sternotomy with valve replacement or repair requires 1 to 3 months. You can return to your daily activities in 4 to 8 weeks if they do not involve strenuous activities and most report having much more energy to do so.

Port-assisted coronary artery bypass (PACAB)

As already mentioned, the longer the need for cardiopulmonary bypass in all on-pump surgery, the greater the risk. When opting for minimally invasive pump surgery it is essential not only to match the criteria of this type of operation but also to consult with a surgeon who has both skill and experience specifically in PACAB techniques. This will mean your surgeon can work more rapidly and your time on CPB will be shorter. 

PACAB or PortCAB procedures avoid total sternotomy in order to achieve a 6 to 8 day hospital stay instead of a 7 to 10 day stay through lower postoperative pain, the option of more extensive heart manipulation with less complications, reduced need for a heart stabilization device (also to avoid perioperative complications), and the avoidance of sternum wires. This operation is a combination of endoscopic MIDCAB with cardiopulmonary bypass. 

With PACAB, heart valves can also be accessed through incisions in the heart wall; coronary arteries running around the back of the heart can also be treated. However, access is limited and on-pump time is crucial to recovery; an experienced surgeon is essential.

Incisions or approximately 5 to 10 cm are made either in the centre of the chest or between the ribs; the surgeon carefully positions his instruments close to the heart. Two catheters are inserted through the groin - 1 into the femoral vein, the other into the femoral artery. The venous catheter follows a network of large veins to enter the vena cava. The arterial catheter is inserted into the femoral artery and guided into the aorta. If atherosclerosis is present, an arterial femoral catheter will not be used. Instead, a cannula is placed directly into the aorta. 

The heart lung machine, connected to the cannulas, then takes over the role of the heart and keeps your blood at the right temperature, filters it, and oxygenates and feeds the body tissues during the operation. It is then time to stop the heart with cardioplegic drugs. Your body is also cooled down. This is to protect your brain and other organs by reducing their need for oxygen and energy. In off-pump procedures, cooling of the body temperature is not part of the procedure.

The surgeon can attach bypass grafts in a blood-free area without shunts using long, thin instruments via the chest incision and a camera. This portion of the operation can take a long time with multiple grafts or a less experienced surgeon. When done, small wires are placed inside the chest wall that can be connected to an electrical pacemaker if necessary. The heart is restarted using a defibrillator machine on the pre-placed defibrillator pads.

The cardiopulmonary bypass machine rewarms your blood to body temperature as the surgeon makes sure no air is left in the heart. When he or she is satisfied, the heart-lung machine is disconnected from the cannulas and they are removed. Heart function is then restored

After your surgery you will not be woken up straight away but brought to the intensive care department under general anaesthetic. After approximately 4 to 6 hours the decision will be made by the intensive care physician to gently wake you and take out your breathing tube. You may drink sips of water after a further 4 hours and may be offered a light meal after around 8 hours of waking. Pain is controlled with intravenous medication, sometimes with a pain pump. You will remain in the intensive care department for 1 to 2 nights under careful monitoring. A physiotherapist will visit to help you with breathing exercises. You should be able to get out of bed within 48 hours of being woken from the general anaesthetic.

Upon arrival at the cardiology department, your urinary catheter will be removed. Intravenous and arterial catheters are usually left in place. If your heart does not show any signs of arrhythmia (irregular heartbeat), the pacing wires placed on the outside of the heart will be gently pulled out. This is an unpleasant sensation but not associated with pain. Your surgeon will make regular visits and prescribe anticoagulant medication that must be taken as instructed. Over the next 24 hours, the arterial catheter will be taken out of your wrist.

Minimally invasive on-pump coronary artery bypass surgery involves a 6 to 8 night hospital stay depending on your preoperative symptoms and surgical results. The intravenous catheter is removed 24 to 48 hours before discharge. 

You will be transported home after your surgeon is satisfied with your progress with written instructions in your language of choice. Trained nursing staff is provided, as is help with meals and transportation to all follow-ups. 

It is possible to fly home 5 days after your operation; however, your surgeon may need to fill in a form for your airline which we will arrange. It is also advised not to travel alone. If necessary, we can provide medically-trained personnel to accompany you. Full recovery from a successful PACAB requires 4 to 6 weeks. You can return to your daily activities after this time weeks if they do not involve strenuous activities.

Benefits of heart bypass surgery

When the sole problem with your heart is the presence of semi-blocked coronary arteries and these are treated by an expert surgeon, blood flow to the body is rapidly improved with less work for the heart and a lower risk of developing other disorders associated either with lack of oxygen or high or low blood pressure. All heart surgery has risks; however, by treating a heart condition before it has the opportunity to worsen while you are still healthy enough for surgery can make a huge difference to the outcome and your future quality of life.

As atherosclerosis affects so many men and women across the globe, significant research into its treatment has meant that coronary bypass surgery has become much safer. The more recent use of internal thoracic artery grafts instead of venous grafts means that 90% of bypass grafts are patent and disease free after 10 years. The ability to operate on multiple coronary arteries during a single surgery has also many advantages. Angina sufferers treated with medication or PCI have less symptom relief than those who have undergone CABG surgery, either on or off pump. Relief of symptoms means better physical health and higher activity levels that significantly improve quality of life. Well over half of CABG patients report that they no longer suffer from shortness of breath after the recovery period.

No good surgeon will advise coronary bypass surgery unless the pros outweigh the cons. Ask for up to 3 free Second Opinions with Remedazo and you can compare what top specialists say regarding your personal medical needs.

Disadvantages of heart bypass surgery

The chance of postoperative infection is high and patients are administered antibiotics as a preventive measure both before surgery commences and after. Your chosen clinic’s cardiologists, cardiothoracic surgeons and nurses are trained to recognise the symptoms of infection very early on, as well as the many other potential complications.

Cardiopulmonary bypass has its own risks that include reactions to some of the drugs used in preparation of coming off the machine. Hospital stays are longer after CPB due to imbalances of various chemicals in the blood, heart rhythm disorders, blood clotting disturbances, acute kidney injury, brain-related symptoms and inflammatory responses due to your blood being in contact with the cannulas. Rewarming the body may also cause inflammation inside the tissues. The blood pressure needs time to stabilize.

Off-pump surgeries may need to become on-pump procedures during the operation. This possibility and its consequences will be explained to you in detail by your treating surgeon well before your planned operation. While this does not occur often, it is best to arrange an open return ticket when arranging your stay.

Other risks of coronary bypass surgery are bleeding, arrhythmia, cardiac tamponade (where the sac around the heart fills with fluid and prevents the heart from beating properly), breathing problems and myocardial infarction (heart attack). This is why pacing wires are placed during many surgeries and why you will be carefully monitoenvironment. Blood transfusions may be required. If you are concerned about the use of donor blood you may be able to arrange autologous blood donation prior to surgery. Cardiopulmonary bypass machines are usually backed up by cell saver machines that salvage blood lost during surgery. All coronary bypass surgeries require post-operative physiotherapy; for total sternotomy this is composed of multiple sessions. For larger incisions patients are taught how to get out of bed and stand and are encouraged to spend time doing breathing exercises. Incisions between the ribs cause high levels of pain which, if not treated with sufficient medication, may discourage an individual from taking deeper breaths and increasing risk of lung infection. All hospitals working with Remedazo adhere to excellent standards of care.red either on a cardiology ward or in intensive care until your doctor feels you are able to move to a less critical 

Follow-ups after these surgeries need to occur at regular intervals and should include blood and exercise testing with electrocardiogram. Bleeding is also a longer-term complication due to the necessity of blood-thinning medications. 

For these reasons we recommend you visit your local cardiologist upon returning home so he or she can keep an eye on your progress. We will provide you with a complete medical report to bring to your local treating physician.

It is important to add that around half of coronary artery bypass patients experience a period of depression after surgery that can last a few day, weeks, months and even years. Isolation, the realisation that life has changed and discomfort are the most commonly reported reasons. Those who return to their daily activities more quickly are less likely to suffer from long-term depression. With holistic goals that set us apart from other medical tourism concerns, Remedazo provides solutions for every need. We introduce you to medical experts working in the finest accredited hospitals, but our services organically extend to providing for your psychological and emotional needs. Remedazo caters for accompanying family members and friends and help you adapt to a healthier lifestyle through the provision of specially-trained catering staff, physical therapists and/or personal trainers and equipped, comfortable surroundings. If you travel alone and just need someone to chat to, we can arrange that, too. All Remedazo team members are picked for their excellent ethics; infused with empathy, understanding and a willingness to listen.

Heart bypass surgery alternatives

It is possible that you have been given a choice of one or more alternative treatments or have not yet made an appointment for your free e-consult and are simply browsing the possibilities.

An alternative to the above-described surgeries is coronary angioplasty, more recently known as percutaneous coronary intervention or PCI. Another name is percutaneous transluminal coronary angioplasty (PTCA). This procedure uses balloons to push open narrow portions of the coronary arteries and may or may not include the placement of a stent. PCI is described in more detail on the angioplasty page.

Lifestyle changes can slow or prevent further build-up of atherosclerosis; however, when plaques have formed and associated symptoms of heart damage appear, treatment is required. If the symptoms are mild, pharmaceutical solutions may be alternatives for coronary artery bypass and angioplasty balloon surgeries. Drugs can work in various ways. Cholesterol-lowering drugs slow down further narrowing and a few case reports say that some plaque deposits may become thinner.

Other drugs do not treat atherosclerosis but the symptoms of IHD. Aspirin lowers the risk of blood clot formation, as do other anticoagulant therapies. Beta blockers slow the heart rate, reducing the heart muscle’s need for higher levels of oxygen. Calcium channel blockers, ACE inhibitors and nitro-glycerine dilate the larger arteries, allowing more blood to flow into the heart and other tissues. If you have high blood pressure, these drugs can lower it. All medication therapies need to be closely followed by your cardiologist

Of course, there is no alternative for professional medical advice. Please call us to arrange your free e-consult and the opportunity to speak personally with specialist (paediatric) cardiologists and (paediatric) cardiothoracic surgeons. You can discuss heart bypass surgery options with them, ask for second or third opinions, and take the first step towards your personalised Remedazo holistic care package.