Coronary artery bypass grafting (CABG) is the most commonly performed heart surgery. CABG is required when one of more the blood vessels (coronary arteries) that supply oxygen-rich blood and nutrients to the heart muscle become narrow or blocked. Narrowing and blockage of the arteries is caused by a build-up of fat, calcium & cholesterol (plaque) on the walls of the arteries, this is known as coronary artery disease. If left untreated, severe coronary artery disease can cause angina (chest pain or discomfort), shortness of breath and in some cases, heart attack.
To reduce adverse outcomes of coronary artery disease, your cardiologist may refer you to a Cardiothoracic Surgeon for consideration of CABG if medical management or minimally invasive stenting procedures are inadequate.
Prior to Surgery
Your cardiothoracic surgeon will discuss in detail the procedure, as well as the risk factors and benefits involved. You will be able to discuss any concerns or questions you may have with your surgeon prior to surgery. It is recommended that you have a family member or friend present with you when you meet your doctor.
Once you have discussed your surgery with the surgeon you will be asked to sign a consent form to indicate that you agree to the surgery and understand the risk factors and benefits involved.
You may feel overwhelmed by all the information that is given but it is important that you understand what is involved with cardiac surgery, if at any time you have any concerns or questions please speak with your surgeon.
You will be asked to send a list of your current medication to your surgeons’ office.
Please include any over the counter medications (e.g.: Panadol, Ibuprofen, Cold & Flu Tablets), antibiotics, vitamins, herbal supplements, performance enhancing/sports supplements. If you are required to cease any medication, you will be advised prior to your surgery.
Please notify your surgeons office as soon as possible if you take any of the following medications:
- Clopidogrel (Plavix)
- Ticagrelor (Brilinta)
- Apixaban (Eliquis)
- Rivaroxiban (Xarelto)
- Warfarin (Coumadin)
- Aspirin (Cartia, Astrix, Spren)
- Empagliflozin (Jardiance)
- Dapagliflozin (Forxiga)
- Canagliflozin (Invokana)
You will need to stop taking fish and krill oil 5 days prior to surgery, you should continue to take all other regular medication unless advised otherwise.
Preparing for Surgery
In the lead up to your operation you should eat a healthy diet low in fat, salt and sugar and plenty of fresh fruits & vegetables.
You should quit smoking immediately. If you continue to smoke you need to let your surgeon know.
If you have been advised to stop taking any medication, you need to do so as directed.
You will need to organise for someone to bring you to hospital and to collect you from the hospital when you are discharged. You should arrange for someone to collect your mail and care for your pets.
You will need to arrange for someone to stay with you for the first two week following surgery. If you don’t have someone that can stay with your following surgery, it is safe to be alone however, it is important to remember that you will be limited in what you can do. You should consider making arrangements with community care services to assist with things such as nursing care (for wound management), meals, yard maintenance, general cleaning & laundry.
Risks & Benefits
As with any surgery, there are risks involved. Risks are related to age, fitness level, other medical conditions and smoking history, your surgeon will discuss the risks and benefits involved in detail prior to surgery.
Risks may include:
- Heart attack (1 - 2%)
- Bleeding during or after the surgery
- Lung infection
- A change in heart rhythm
- In rare cases, death
Benefits may include:
- Having more energy
- Reduced risk of heart attack
- Reducing / eliminating discomfort caused by angina
- Reducing discomfort caused by shortness of breath
Most standard CABG procedures take 3 – 5 hours depending on the number of bypasses you require.
Your Healthcare Team
During your stay in hospital, you will be cared for by a team of highly skilled doctors and nurses, this includes:
- Cardiothoracic Surgeon
- Surgical Assistant
- Intensive Care Doctor
- Theatre Nurses
- Cardiac Nurses
The evening before your procedure you will have your chest, arms and legs shaved. You will be asked to have a shower using a specially medicated sponge or wash.
You may be given a sleeping tablet to help you get a good nights’ rest prior to surgery.
You will be required to fast for 8 hours prior to surgery. You may have a small amount of water with your medication.
On the day of your procedure you will have another shower with the medicated sponge or wash, you will then be asked to dress in a theatre gown and pants.
Prior to going to surgery your nurse will give you your pre-operative medication, you will be able to take this with a small amount of water. Once you have taken your medication, you will be required to remain in your bed. You may also be given some oxygen while you wait to be taken to theatres. Urinary catheter and cannula now???
You will be taken to an anaesthetic room in theatre where a nurse will explain the next steps. The anaesthetist will give you a general anaesthetic through a cannula inserted in your hand, you will then fall asleep. Your anaesthetist will continue to monitor you for the duration of your surgery. Once you have received your anaesthesia, you will be taken to the operating theatre.
One or more healthy veins or arteries will be removed from your chest, leg or arm in preparation for your bypass. A 15cm incision will be made in your chest. Your sternum (breast bone) will be opened down the centre to allow the doctor access to your heart. You will be placed on a bypass machine and your heart will be stopped. The bypass machine will take over for the heart and lungs continuing to pump oxygenated blood through the body, once your heart has been stopped. This machine will be monitored by the Perfusionist for the duration of your procedure.
Your aorta will be clamped off to stop blood following into the heart while the doctor performs the bypass, this is called cross clamping. The vein or artery taken earlier from the chest, leg or arm will be used to form a graft and bypassed around the diseased artery to restore normal blood flow to the heart. One end of the graft will be attached (sewn) to the aorta and the other end will be attached to a small opening below the blockage in the diseased coronary artery. If a mammary artery (chest) is used, one end remains attached to the aorta while the other is attached to the coronary artery.
Once all the bypasses are completed, your cross clamp will be taken off, the doctor will check your heart is pumping at a regular steady rate and you will be removed from the bypass machine. The doctor will close your sternum with stainless steel wires and your incision will be closed with dissolving stitches. You will have some plastic tubes or drains left in place to allow drainage of remain blood and fluid from around the heart. You will also have a pacing wire which helps the heartbeat get back to a normal rate if it has been temporarily out of rhythm. Your surgeon will call your next of kin once your surgery is complete.
Breathing tube when?
Intensive Care Unit (ICU)
Once your surgery is complete you will be taken to the ICU. Your breathing tube will remain in place and connected to a ventilator to help you breathe. As you come out of anaesthetic, you will begin breathing on your own and your breathing tube will be removed. Once your breathing tube has been removed you will receive oxygen through a mask.
Your chest tube will be removed over the next few days as the draining of fluid begins to subside. Your drips and urinary catheter will also be removed as your condition begins to improve.
You will remain in ICU for 1 - 2 days following your procedure.
Cardiothoracic Unit (CTU)
From ICU, you will be transferred to the cardiothoracic unit where you will stay for 3 – 5 days before being discharged home. The nurses will assist you with most of your activities such as sitting out of bed, toileting, showering and getting dressed. As you become stronger, you will be able to start doing these activities unaided.
You will be encouraged to walk with the assistance of a physiotherapist who will visit your daily. The physiotherapist will also to show you deep breathing exercises to help with your recovery. Your blood pressure, heart rate, temperature will be regularly monitored while you are in the CTU. You will be weighed daily to ensure fluid retention is reducing. You will have regular blood tests chest x-rays while you are in hospital.
Some of your medications may have been changed or stopped after surgery. Often you will be given diuretics (water tablets) to remove any excess fluid from the body, and potassium supplements. You may also receive laxatives to help you with going to the bathroom. Normally these will be ceased before you go home. You will be given oral pain medication every 4 to 6 hours. If you are unable to perform your physiotherapy exercises, walk or move about due to the pain, please tell your Nurse.
When you are discharged from hospital you will be given a list of your medications with instructions on how much to take and when, you must continue to take all medications as directed by your doctor.
It is important to minimise strain and support your sternum following surgery and a chest pillow will help you do this. You should keep your chest pillow close at all times in case you need to support your chest when you cough or sneeze. You will be able to purchase a chest pillow from the CTU.
If you had veins harvested from your legs, you will be given compression stockings to wear to help with circulation. Your nurse will show you how to put on and remove your stockings. Your stockings should be washed in the evening and left overnight to dry ready for the next day. You should continue to wear your compression stockings for 4 – 6 weeks after surgery. Wear overnight????
You will be discharged 7 – 10 days after surgery. Once you are discharged from hospital it is safe for you to travel by car as a passenger. You can safely wear a seatbelt, if you experience any discomfort use your chest pillow as a buffer between your chest and seatbelt. If you are travelling long distances (more than 1 hour), it is strongly recommended that you stop regularly to get out of the car and move around.