What To Expect During Coronary Artery Bypass Grafting

Coronary artery bypass grafting (CABG) requires a team of experts. A cardiothoracic surgeon performs the surgery with support from an anesthesiologist, perfusionist (heart-lung machine specialist), other surgeons, and nurses.

There are several different types of CABG. They range from traditional surgery in which the chest is opened to reach the heart, to a nontraditional surgery in which small incisions are made to bypass the narrowed artery.

Traditional Coronary Artery Bypass Grafting

This type of surgery usually lasts 3 to 5 hours, depending on the number of arteries being bypassed. Numerous steps take place during traditional CABG.

Anesthesia is given to put you to sleep. During the surgery, the anesthesiologist monitors your heartbeat, blood pressure, oxygen levels, and breathing. A breathing tube is placed in your lungs through your throat, and connected to a ventilator (breathing machine).

An incision is made down the center of your chest. The chest bone is then cut and your ribcage is opened so that the surgeon can get to your heart.

Medicines are used to stop your heart, which allows the surgeon to operate on it while it's not beating. A heart-lung machine keeps oxygen-rich blood moving throughout your body. An artery or vein is taken from a different part of your body, such as your chest or leg, and prepared to be used as a graft for the bypass. In surgery with several bypasses, a combination of both artery and vein grafts is commonly used.

• Artery grafts. These grafts are much less likely than vein grafts to become blocked over time. The left internal mammary artery is most commonly used for an artery graft. It's located inside the chest close to the heart. Arteries from the arm or other places in the body are sometimes used as well.
• Vein grafts. Although veins are commonly used as grafts, they're more likely than artery grafts to develop plaque and become blocked over time. The saphenous vein-a long vein running along the inner side of the leg-is typically used.

After the grafting is complete, your heart is restarted using mild electric shocks. You're disconnected from the heart-lung machine. Tubes are inserted into your chest to drain fluid.

The surgeon uses wires that stay in your body permanently to close your chest bone and stitches or staples to close the skin incision. The breathing tube is removed when you're able to breathe without it.

Nontraditional Coronary Artery Bypass Grafting

Nontraditional CABG includes off-pump CABG and minimally invasive CABG.

Off-Pump Coronary Artery Bypass Grafting

This type of surgery can be used to bypass any of the coronary arteries. Off-pump CABG also is called beating heart bypass grafting because the heart isn't stopped and a heart-lung machine isn't used. Instead, the part of the heart where grafting is being done is steadied with a mechanical device.

Off-pump CABG may reduce complications that can occur when a heart-lung machine is used, especially in people who have had a stroke or "mini-strokes" in the past, who are over age 70, and who have diabetes, lung disease, or kidney disease.

Other advantages of this type of bypass surgery include:

• Reduced bleeding during surgery and a lower chance of needing a blood transfusion
• A lower chance of infection, stroke, and kidney complications
• A lower chance of complications such as memory loss, difficulty concentrating, or difficulty thinking clearly
• Faster recovery from the surgery

Minimally Invasive Direct Coronary Artery Bypass Grafting

There are several types of minimally invasive direct coronary artery bypass (MIDCAB) grafting. These types of surgery differ from traditional bypass surgery because they only require small incisions rather than opening the chest bone to get to the heart. These procedures sometimes use a heart-lung machine.

MIDCAB procedure. This procedure is used when only one or two coronary arteries need to be bypassed. A series of small incisions is made between your ribs on the left side of your chest, directly over the artery to be bypassed. The incisions are usually about 3 inches long. (The incisions made in traditional CABG are at least 6 to 8 inches long.) The left internal mammary artery is most often used for the graft. A heart-lung machine isn't used during this procedure.

Port-access coronary artery bypass procedure. This procedure is performed through small incisions (ports) made in your chest. Artery or vein grafts are used. The heart-lung machine is used during this procedure.

Robot-assisted technique. This type of procedure allows for even smaller, keyhole-sized incisions. A small video camera is inserted in one incision to show the heart, while the surgeon uses remotely controlled surgical instruments to perform the surgery. The heart-lung machine is sometimes used during this procedure.

Advantages of minimally invasive CABG include smaller incisions, smaller scars, shorter recovery and hospital stay, less bleeding, less chance for infection, and less pain.