This guide was written by Donna Rosborough, MS, RN, CCRN and Sary Aranki, MD.
It is not to be reproduced without permission from the authors.
Coronary Artery Bypass Surgery at Brigham and Women's Hospital
If you are scheduled for surgery at Brigham and Women's Hospital to restore blood flow in your heart, you can expect to receive the highest quality of skill and care available anywhere. Brigham and Women's Hospital is one of the premier centers for conventional coronary artery bypass surgery. Brigham and Women's Hospital is one of very few centers that specialize in treatment of advanced forms of coronary artery disease that are considered inoperable elsewhere (such as high risk reoperative coronary artery bypass surgery, coronary endartarectomy, transmyocardial laser revascularization, and future use of gene therapy.)
Every year, our cardiac surgeons perform more than 1,100 coronary artery bypass surgeries, including "minimally invasive" procedures. In addition to having experienced surgeons at Brigham and Women's Hospital, you will be cared for by a collaborative team of nurses, physician assistants, physical therapists, dietitians, and social workers.
We hope this brochure helps you and your family understand what to expect with your coronary artery bypass surgery-from preadmission to discharge. If, after reading it, you have any questions, please ask a member of the cardiac surgery team. We are available to you at the hospital seven days a week.
CARDIAC STAFF SURGERY
Lawrence H. Cohn, M.D., Chief
Sary F. Aranki, M.D.
John G. Byrne, M.D.
Gregory S. Couper, M.D.
Robert J. Rizzo, M.D.
Your Heart/Coronary Arteries
Your heart is a pumping muscle responsible for circulating oxygen-rich blood throughout your body. There are four chambers inside your heart: the two upper chambers are called atria and the two lower chambers are called ventricles. The heart muscle squeezes blood from chamber to chamber.
Your heart contains coronary arteries, tubelike branches, which are attached to your aorta (the large blood vessel that carries blood and oxygen from your heart to the rest of your body).
Your Heart and Its Blood Supply
The right and left coronary arteries wrap around your heart and feed it with oxygen-rich blood. The right one mainly feeds the bottom and right side of the heart, including the right ventricle-the chamber that pumps oxygen-poor blood to the lungs. The left one feeds the rest of the heart, including the back and the left ventricle-the chamber that pumps blood, returned from the lungs recharged with oxygen, through the aorta to the rest of the body. The coronary arteries get their blood from the aorta.
Coronary Artery Disease
Coronary arteries can become diseased when cholesterol, a fatlike substance carried in the blood, builds up to form plaque (fatty substances and calcium) in the lining of the artery. Blood and oxygen may no longer flow easily to the heart muscle which may cause angina (pain, discomfort or pressure in the chest that is caused by an insufficient supply of blood to the heart). You may develop a heart attack (myocardial infarction) if blood flow is completely blocked by plaque or by a blood clot that forms inside the narrowed coronary artery.
Risk factors for coronary artery disease are:
- gender
- age
- family history
- smoking
- high blood pressure
- high fat and cholesterol diet
- excessive alcohol intake
- overweight
- lack of exercise
- diabetes
Symptoms of coronary artery disease seldom appear until a coronary artery has narrowed by 70% or more. Tests can show whether any of the coronary arteries have become narrowed. This will help determine the best course of treatment.
Diagnostic Testing
In order to diagnose and determine treatment for coronary artery disease, your doctor will obtain a complete medical history, perform a thorough physical exam, and order any or all of the following special diagnostic tests.
- Chest x-ray: x-rays can provide doctors information about the size of your heart and its four chambers, as well as information about your lungs.
- Electrocardiogram (EKG): this test records the changes of electrical activity occurring during your heartbeat. It helps to diagnose any irregularities in your heart's rate and rhythm, as well as in heart muscle enlargement or damage.
- Echocardiogram (Echo): this test uses ultrasound to examine and measure the structure of your heart. An echo demonstrates performance of the heart valves and provides information on heart muscle function.
- Stress test: this test records your heart's electrical patterns while you exercise on a treadmill. It shows whether your heart responds normally to physical exertion.
- Nuclear Scan: this test can detect coronary artery disease. A small amount of radioactive material is injected into a vein while you are resting or exercising. The material is temporarily absorbed by your heart and a scanning camera can detect parts of the heart that are not receiving enough blood flow due to narrowed coronary arteries.
- Cardiac Catheterization (Coronary Angiogram): this test allows physicians to see your blood vessels and measure the pressures inside your heart chambers following injection of a contrast dye. It also evaluates heart pumping function and any obstruction of the coronary arteries that supply blood to your heart muscle.
Coronary Artery Bypass Graft Surgery (CABG)
Coronary artery bypass graft surgery (CABG) creates new pathways around the areas of your blocked arteries, allowing blood flow to be restored. Your blocked coronary arteries are bypassed with an artery or vein taken from another part of your body (leg, chest, or arm).
The grafts most commonly used are:
- Internal mammary or thoracic arteries located along the inside of your chest wall: There is documented long-term graft patency.
- Saphenous veins located in your legs : A new minimally invasive technique makes it possible for the greater saphenous vein to be dissected and slipped out through a small incision. A reduction in wound complications, quicker postoperative mobility, and less pain are some of the advantages to this new technique.
- Radial arteries located in your arms : These blood vessels may be an option for cardiac surgeons when saphenous veins are unavailable.
The average time required for coronary artery bypass graft surgery is four hours. Your surgery will be performed by a specialized team:
- Your cardiac surgeon will perform the surgery.
- Surgical assistants will assist with the surgical procedure.
- Nurses will provide surgical instruments and supplies to the team.
- Anesthesiologists will provide youfreedom from pain and a deep sleep that prevents any memory of surgery.
- Perfusionist will operate the heart-lung machine that keeps your blood circulating with oxygen.
Coronary artery bypass graft surgery can be performed by different surgical approaches:
Your doctor will take a blood vessel from your chest or from your leg or arm. One end is attached to your aorta (the large artery that comes out of the heart), and the other end is attached to the coronary artery below the point where it's clogged. Blood can now flow through the new channel to the heart.
New Techniques for the Treatment of Coronary Artery Disease
"Minimally Invasive CABG"
A trend towards less invasive cardiac surgical procedures is under development. This involves smaller scars and avoidance of the heart-lung machine. This expanding field is in evolution with new techniques and instruments being developed and introduced all the time. The ultimate aim is to achieve similar results to currently practiced conventional techniques.
We currently offer coronary artery bypass surgery on a beating heart and without the heart-lung machine in about 5-10% of patients. These are patients at a higher risk for developing complications related to the heart-lung machine.
Transmyocardial Laser Revascularization (TMR)
When your physician finds that your heart disease can no longer be managed with medications, coronary artery bypass graft surgery, or percutaneous balloon angioplasty (PTCA), TMR may be recommended. Patients are considered candidates for this surgical procedure if they meet specific medical criteria.
TMR is a surgical procedure which involves the creation of laser-drilled holes in areas of the heart that have not been receiving enough blood supply from your coronary arteries. The process involves creating a channel into the heart muscle to improve circulation. It is unknown exactly how this works. However, the majority of patients (75%) receive significant symptom relief that can range from days to months.
If after consultation with your cardiologist and cardiac surgeon you are considered to be an eligible candidate you will receive an additional brochure outlining more specific information about the procedure, postoperative recovery, and follow-up.
Preparing for Surgery
Once coronary artery surgery has been recommended and scheduled by your cardiac surgeon, you will be admitted the day of or day before your surgery. Patients scheduled to be admitted on the day of surgery will have an appointment scheduled in the preadmitting test center (PATC) within the preceeding two weeks. All patients will be given diagnostic tests, a physical examination, and will be seen by members of the cardiac surgery and anesthesia teams. A nurse will discuss the intensive care unit (ICU), postoperative recovery and discharge planning procedures with you and your family.
- Smoking: If you smoke, you should stop. Smoking constricts the coronary arteries, produces excess secretions in the lungs, raises blood pressure and increases the heart rate. The potential for complications increases after surgery if you continue to smoke.
- Banking Blood: In advance of your surgery, you may be able to set aside blood in the Brigham and Women's Hospital blood bank so that it is available to you during and/or after your surgery. Your cardiac surgeon will determine the amount required and whether your medical condition will allow you to donate blood for yourself. Family members and/or friends may also donate blood for you if they meet eligibility criteria. Blood may be donated at the Brigham and Women's Hospital blood bank or at a local center and then shipped to Brigham and Women's Hospital.
- Anticoagulants: If you are taking Warfarin (brand name Coumadin®) or medications containing aspirin, you will be instructed to discontinue them prior to your surgery. The cardiac surgeon's secretary will include this information in your pre-admission letter.
- Advance Directives/Health Care Proxy/Living Wills: If you have completed a living will or named a proxy, bring copies with you for your medical file. We encourage you to discuss any important personal values and/or medical care preferences with your primary care physician, cardiologist or cardiac surgeon prior to admission. If you have not completed a proxy or living will document, forms are available through the Brigham and Women's Hospital Admitting Office.
- Diet Restrictions: Until midnight the day before your surgery, you may eat and drink as usual. After midnight, however, do not eat or drink anything. This helps decrease any nausea and vomiting associated with anesthesia. If you have prescribed medications, use only a small amount of water.
- Pre-operative Preparation: Patients will be transported to the pre-operative holding area outside the operating room a few hours prior to surgery. Here, the anesthesia team will insert an intravenous line (IV) to sedate you and some other lines to monitor your heart and blood pressure. Once the operating room team is prepared for your surgery, the anesthesiologist will take you to the operating room. You will be anesthetized; an endotracheal tube (breathing tube) will be inserted; and other tubes and lines will be placed to monitor your respirations, and other bodily functions. If you are interested in listening to music during surgery, please bring a portable radio, batteries, and your favorite selection of music to help you relax.
- Waiting During Surgery: While you are undergoing cardiac surgery, your family may wait in the hospital or at home. Family members and friends can wait in the Family Liaison area of the Bretholtz Center for Patients and Families located in the main lobby. Following the operation, your cardiac surgeon will personally speak with your family. After speaking with the surgeon, your family must wait one hour before visiting you in the ICU, in order to give the nursing staff sufficient time to assess your condition.
The Intensive Care Unit
Immediately after surgery, you will be taken to the cardiac surgery intensive care unit (ICU) where a team of specially trained physicians and nurses will take constant care of you and monitor your vital signs and other vital bodily functions as you recover from the effects of anesthesia. The special intravenous catheters, tubes, and drains placed in the operating room will remain in place. At that time:
- You will be connected by an endotracheal tube to a venti-lator (breathing machine) until you are awake enough to breathe on your own. You will not be able to talk while this tube is in place because it is positioned between your vocal cords. Most patients are able to have the tube removed on the day of surgery. Once the tube is removed, you will wear an oxygen mask for additional oxygen and humidity.
- Your heart function will be monitored. An EKG will continue to monitor your heart rate and rhythm; a special intravenous catheter (arterial line) will measure your blood pressure and allow the nurse to draw blood samples; a probe on your finger (pulse oximeter) will measure your oxygenation; and sometimes a special intravenous catheter will have been inserted to measure pressures inside your heart (pulmonary artery catheter).
- A urinary catheter in your bladder will drain urine into a bag. Chest tubes will drain blood and fluid from your chest incision into a special container to prevent a collection from forming around your heart.
- Temporary pacemaker wires may be placed in your heart; if your own heart rate becomes too slow following surgery, you may require a pacemaker temporarily.
Once you recover from anesthesia you'll be an active participant in your recovery. You will be encouraged to take deep breaths and cough to help eliminate anesthesia and secretions from your lungs. You will be instructed to wiggle your toes and flex your feet hourly. It is also important to exercise your legs to help improve blood flow and prevent blood clots. The nurse will also place elastic stockings on your legs to help your circulation and decrease swelling in your legs.
Pain medication will be available to you intravenously on the day of surgery. The day after surgery, when the endotracheal tube is removed and you are able to take liquids, you will take your pain medications by mouth. It is important to take pain medication for the first couple of days to enable you to cough, to breathe deeply, and to increase your ability to walk with assistance.
Visitors
Immediate family and close friends are allowed in the ICU 24 hours a day. However, prior to each visit, all visitors must call from one of the family rooms on the floor. The ICU is a busy place and the nursing staff may be busy with your family member or other patients. Please respect patients' privacy at all times.
Postoperative Recovery
Once the cardiac surgery team determines that you no longer need to be in the ICU, you will be transferred to a unit where your heart can continue to be monitored as needed. Most patients are able to be transferred out of the ICU the day after surgery.
Exercise
To increase blood flow and improve muscle strength, it is important to gradually increase your level of activity. Walking is one of the simplest ways to help yourself recover. The nursing staff will assist you in walking initially and encourage you to increase the distance and frequency daily. Your primary care physician or cardiologist may recommend an outpatient cardiac rehabilitation program, which can help you resume a healthy, active lifestyle through exercise and education. The rate of recovery will depend upon your age, general health and your heart function.
Care of Your Incisions
Once all of the tubes, lines and wires are discontinued, you will be encouraged to shower daily with warm water and a mild soap to keep your incisions from becoming infected. If your incision was made in your breastbone, do not lift anything over 10 pounds for three months after surgery. Your breastbone needs time to heal properly.
Medications
During your hospitalization medications will be prescribed and carefully adjusted for you. Common medications include fluid pills, potassium, blood pressure pills, and medications to control a rapid/irregular heartbeat. Your nurse will review with you your medications, including the correct dosage, frequency and side effects.
Nutritional Needs
Good nutrition is important for healing. It is very important that you:
- keep your weight within the normal range for your age and body frame.
- reduce your salt intake to prevent fluid retention that may overload your heart and cause it to work inefficiently.
- eat low fat, low cholesterol, high fiber foods.
To monitor fluid retention, weigh yourself daily until your follow-up appointment with your physicians. If you gain 3 pounds or more in one day, tell your doctor. A dietician will be available to meet with you and your family to review nutritional guidelines recommended after coronary artery surgery.
Nutrition Guidelines After Coronary Artery Surgery:
- Eat Less Fat: limit fats to one-third of your total calories; reduce the amount of saturated fat you eat such as butter, "partially hydrogenated oils," and fatty meats.
- Watch your Cholesterol intake: limit your use of foods such as eggs and fatty meats.
Eat More Fiber : oats, beans, and fruit are rich in soluble fiber.
- Eat More Starches: starches are not fattening and can lower your cholesterol level by "diluting" the fat you eat; eat more grains, beans, and root vegetables.
- Drink Less Alcohol: drinking too much alcohol may raise your cholesterol level by raising the fat levels in your blood; try to limit yourself to no more than two alcoholic beverages each day.
Discharge Planning/Follow-up
Home Care
Generally, most patients can leave the hospital 4-5 days following surgery. It is important to have family members or friends available to assist you in your first week at home. The nursing staff will contact a home care agency near your home to arrange a home nursing assessment the day after your discharge. Additional services are available through the home care agencies for patients who meet certain criteria for physical therapy, occupational therapy, and the services of a home health aide, or social worker.
Cardiologist
It is important to make an appointment with your cardiologist within two weeks of discharge. Your cardiologist will monitor your progress over time and adjust your medications.
Cardiac Surgeon
Patients will also need to make an appointment with their cardiac surgeon four to six weeks after discharge. The cardiac surgeon's secretary will send you a letter confirming the date, time and location of your appointment. (Patients who live a great distance from the hospital are not required to return for a follow-up appointment with the cardiac surgeon.)
Primary Care Physician (PCP)
Patients who have managed care insurance plans, such as Harvard Pilgrim Health Care and Tufts Health Plan, will also need to make an appointment with their primary care physician within two weeks of discharge. Your PCP coordinates your plan of care with your cardiologist and cardiac surgeon.
Extended Care Facility
If you require physical and occupational therapy or other close medical management, we will refer you to an extended care facility. A team of nurses and social workers will meet with you to discuss available facilities and will make a recommendation based on the clinical care offered at the facility, its location, and your insurance coverage.
Following your discharge from the hospital, a nurse from the cardiac surgery office will call you at home to check on how you are progressing. The nurse will ask about your incisions, activity level, and follow-up appointments. If you are transferred to an extended care facility, the nurse will contact the facility for progress reports.
Cardiac Rehabilitation
By joining a cardiac rehabilitation program, you can improve your chances of resuming a healthy, active lifestyle. An interdisciplinary team may include cardiologists, nurses, therapists, dietitians, and social workers.
Education is a primary focus of such programs and helps patients and families make informed decisions regarding care. Topics include risk factors for heart disease (cigarette smoking, high cholesterol levels, high blood pressure, diabetes, family history of heart disease, obesity, stress, age, and minimal exercise) diet, exercise, and stress management.
A comprehensive initial evaluation is required prior to entering a cardiac rehabilitation program. Eligible candidates are people who have stable angina, have had a heart attack, have had coronary artery bypass surgery, or have had coronary angioplasty.
Cardiac rehabilitation programs are located in many hospitals. You may choose a program near your home or enroll in Brigham and Women's/Faulkner Heart Healthy Cardiac Rehabilitation program by obtaining a written referral from your physician and contacting the nurse manager at (617) 983-7104.
Most insurance providers are required to provide cardiac rehabilitation coverage. However, the number of sessions allowed varies by your insurance provider.
Staying healthy after surgery usually requires paying attention to necessary changes in lifestyle. Feel free to ask us about any other resources available to help you and your family.
