Coronary Artery Bypass Grafting What to Expect During Surgery

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During CABG, a surgical team will take one or more blood vessels from another part of your body and connect it to the blocked artery in your heart.

CABG may be performed in one of three ways.

• In traditional CABG, the chest is cut open and a machine pumps your blood.
• In “off-pump” CABG, the chest is opened, but a machine for pumping blood is not used.
• With minimally invasive CABG methods, only small cuts are made in the chest, and a machine is not used.

Your surgical team may include:

• Cardiothoracic surgeon, who will work on your heart
• Anesthesiologist, who will give you medicine to make you sleep before the surgery, connect you to a breathing machine, and monitor your vital signs throughout the procedure
• Perfusionist, who will manage the heart-lung pump
• Nurses and other surgeons who provide support throughout the surgery

Traditional CABG is the most common type of CABG surgery. This surgery takes about 3 to 6 hours, depending on how many arteries need to be bypassed. Learn more about how to prepare before surgery. You will be given an intravenous (IV) line for fluids and medicines that will make you sleep before the surgery.

You will be connected to a ventilator to support your breathing. The surgeon makes a cut down the middle of the chest, through the breastbone. The bone is split and the rib cage separated so the surgeon can reach the heart.

You will receive medicines to temporarily stop your heart from beating. This makes it easier for the surgeon to connect the healthy blood vessels, called grafts, into the coronary arteries. This requires a heart-lung bypass machine, which adds oxygen to your blood and pumps it throughout your body during surgery while your heart is not beating.

The surgeon will then take an artery or a vein from your leg, arm, stomach, or chest. The graft is connected to the blocked coronary artery. The new blood vessel bypasses the blocked portion to create a new path for blood flow to the heart muscle. The number of grafts depends on how many coronary arteries need to be bypassed.

When the grafting is finished, the surgeon will restart the heart and restore blood flow. The heart usually starts beating on its own, but sometimes mild shocks are used to start it. Surgeons will sew the breastbone back together with a wire.

Sometimes CABG can be done without stopping the heart and using a heart-lung bypass machine. This is called off-pump CABG because the heart-lung bypass machine, or pump, is not used. The heart is steadied with a mechanical device.

This procedure is more difficult for surgeons because the heart is beating, and surgeons do not have easy access to blood vessels. However, it may be safer for certain people, such as those who have a higher risk of complications from using a heart-lung bypass machine. These include older adults and people who have ventricular dysfunction, diabetes, kidney disease, and chronic lung disease. This type of surgery is also sometimes called beating-heart bypass grafting.

Sometimes, CABG surgery may not be done as open heart surgery:

• Minimally invasive direct coronary artery bypass (MIDCAB) is a modified version of CABG where the chest bone is not cut open. Instead, the surgeon makes a smaller cut on the left side of the chest over the artery that needs to be bypassed and enters in between the ribs. It is also usually an off-pump procedure.
• Robotic CABG surgery uses a robot to surgically place the graft. The surgeon controls the robot instead of doing the work by hand, and the machinery only needs small openings in the chest. A heart-lung bypass machine is sometimes used.
• Hybrid bypass surgery uses robotic bypass for one of the main arteries and a stent for other blocked arteries. The stent is a rolled-up mesh tube-like structure that goes inside the blocked artery to hold it open. This procedure is typically used only if your doctor is unable to perform the traditional bypass procedure.

Your heart care team will talk to you about the risks for problems during and after surgery. You will also be monitored closely for any problems that may happen so they can be treated quickly. As with any surgery that involves the heart, there are some risks. The risk is generally higher for people who get CABG in an emergency situation, have plaque in other arteries throughout the body, or have other medical conditions, such as major heart failure, or lung or kidney disease.

Potentially serious problems from CABG may include:

• Arrhythmia, or irregular heartbeat, which may occur after the surgery but usually goes away on its own.
• Bleeding, which may require more surgery to control it
• Heart attack
• Infection, which can occur where the surgical cut was made or inside the chest where the surgery was performed. This may require additional surgeries.
• Kidney failure
• Stroke

Some people experience confusion or problems thinking clearly, temporary memory loss, vision problems, and slurred speech. This is known as postoperative cognitive decline (POCD). These symptoms may occur for a short time right after surgery. The exact cause of POCD is not known. Many factors, including the health of the patient before surgery, likely play a role.