Heart surgery can correct problems with the heart if other treatments haven't worked or can't be used. The most common type of heart surgery for adults is coronary artery bypass grafting (CABG). During CABG, a healthy artery or vein from the body is connected, or grafted, to a blocked coronary (heart) artery.
Doctors also use heart surgery to:
. Repair or replace heart valves, which control blood flow through the heart
. Repair abnormal or damaged structures in the heart
. Implant medical devices that help control the heartbeat or support heart function and blood flow.
. Replace a damaged heart with a healthy heart from a donor
. Treat heart failure and coronary heart disease
. Control abnormal heart rhythms
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Who needs Heart Surgery?
Heart surgery is used to treat many heart problems. For example, it's used to:
. Treat heart failure and coronary heart disease (CHD)
. Fix heart valves that don't work well
. Control abnormal heart rhythms
. Place medical devices
. Replace a damaged heart with a healthy one
If other treatments—such as lifestyle changes, medicines, and medical procedures—haven't worked or can't be used, heart surgery might be an option.
Your primary care doctor, a cardiologist, and a cardiothoracic surgeon will work with you to decide whether you need heart surgery.
A cardiologist specializes in diagnosing and treating heart problems. A cardiothoracic surgeon specializes in surgery on the heart and lungs.
These doctors will talk with you and do tests to learn about your general health and your heart problem. They'll discuss the test results with you and help you make decisions about the surgery.
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Your doctors will talk with you about:
. The kind of heart problem you have and the symptoms it's causing. Your doctor may ask you how long you've had symptoms.
. Your past treatment of heart problems, including surgeries, procedures, and medicines.
. Your family's history of heart problems.
. Your history of other health problems, such as diabetes or high blood pressure.
. Your age and general health.
You also may have blood tests, such as a complete blood count, a lipoprotein panel (cholesterol test), and other tests as needed.
There are many types of heart surgery. One person's experience before surgery can be very different from another's.
Some people carefully plan their surgeries with their doctors. They know exactly when and how their surgeries will happen. Other people need emergency heart surgery. For example, they might be diagnosed with blocked coronary arteries and admitted to the hospital right away for surgery.
If you're having a planned surgery, your doctors and others on your health care team will meet with you to explain what will happen. They'll tell you how to prepare for the surgery. You might be admitted to the hospital the afternoon or morning before your surgery.
You may have some tests before the surgery, such as an EKG (electrocardiogram), chest x ray, or blood tests. An intravenous (IV) line will be placed into a blood vessel in your arm or chest to give you fluids and medicines.
A member of your health care team may shave the area where your surgeon will make the incision (cut). Also, your skin might be washed with special soap to reduce the risk of infection.
Just before the surgery, you'll be moved to the operating room. You'll be given medicine so that you fall asleep and don't feel pain during the surgery.
Tests are done to find out more about your heart problem and your general health. This helps your doctors decide whether you need heart surgery, what type of surgery you need, and when to do it.
. EKG (Electrocardiogram)
An EKG is a painless, noninvasive test that records the heart's electrical activity. "Noninvasive" means that no surgery is done and no instruments are inserted into your body.
The test shows how fast the heart is beating and its rhythm (steady or irregular). An EKG also records the strength and timing of electrical signals as they pass through the heart.
An EKG can show signs of heart damage due to CHD and signs of a previous or current heart attack.
. Stress Test
Some heart problems are easier to diagnose when your heart is working hard and beating fast. During stress testing, you exercise to make your heart work hard and beat fast. If you can't exercise, you may be given medicine to raise your heart rate.
As part of the test, your blood pressure is checked and an EKG is done. Other heart tests also might be done.
Echocardiography (echo) is a painless, noninvasive test. This test uses sound waves to create a moving picture of your heart. Echocardiography shows the size and shape of your heart and how well your heart chambers and valves are working.
The test also can show areas of poor blood flow to your heart, areas of heart muscle that aren't working well, and previous injury to your heart muscle caused by poor blood flow.
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. Coronary Angiography
Coronary angiography is a test that uses dye and special x rays to show the insides of your coronary arteries.
To get the dye into your coronary arteries, your doctor will use a procedure called cardiac catheterization.
A thin, flexible tube called a catheter is put into a blood vessel in your arm, groin (upper thigh), or neck. The tube is threaded into your coronary arteries, and the dye is released into your bloodstream.
Special x rays are taken while the dye is flowing through the coronary arteries. These x rays are called angiograms.
The dye lets your doctor study blood flow through the heart and blood vessels. This helps your doctor find blockages that can cause a heart attack.
An aortogram is an angiogram of the aorta. The aorta is the main artery that carries blood from your heart to your body. An aortogram may show the location and size of an aortic aneurysm.
. Chest X Ray
A chest x ray creates pictures of the structures inside your chest, such as your heart, lungs, and blood vessels.
This test gives your doctor information about the size and shape of your heart. A chest x ray also shows the position and shape of the large arteries around your heart.
. Cardiac Computed Tomography Scan
A cardiac computed tomography (to-MOG-rah-fee) scan, or cardiac CT scan, is a painless test that uses an x-ray machine to take clear, detailed pictures of the heart.
Sometimes an iodine-based dye (contrast dye) is injected into one of your veins during the scan. The contrast dye highlights your coronary (heart) arteries on the x-ray pictures. This type of CT scan is called a coronary CT angiography, or CTA.
A cardiac CT scan can show whether plaque is narrowing your coronary arteries or whether you have an aneurysm. A CT scan also can find problems with the heart's function and valves.
. Cardiac Magnetic Resonance Imaging
Magnetic resonance imaging (MRI) is a safe, noninvasive test that uses magnets, radio waves, and a computer to create pictures of your organs and tissues.
Cardiac MRI creates images of your heart as it is beating. The computer makes both still and moving pictures of your heart and major blood vessels.
Cardiac MRI shows the structure and function of your heart. This test can show the size and location of an aneurysm.
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Chief of cardiac surgery unit
Department of Surgery
Markaz Tebbi Kodakan
Tehran University of Medical Sciences
Tehran – Iran
What Are the Risks of Heart Surgery?
Heart surgery has risks, even though its results often are excellent. Risks include:
. Infection, fever, swelling, and other signs of inflammation.
. A reaction to the medicine used to make you sleep during the surgery.
. Arrhythmias (irregular heartbeats).
. Damage to tissues in the heart, kidneys, liver, and lungs.
. Stroke, which may cause short-term or permanent damage.
. Death. (Heart surgery is more likely to be life threatening in people who are very sick before the surgery.)
. Memory loss and other issues, such as problems concentrating or thinking clearly, may occur in some people.
These problems are more likely to affect older patients and women. These issues often improve within 6–12 months of surgery.
In general, the risk of complications is higher if heart surgery is done in an emergency situation (for example, during a heart attack). The risk also is higher if you have other diseases or conditions, such as diabetes, kidney disease, lung disease, or peripheral artery disease (P.A.D.).
Types of Heart Surgery
. Coronary Artery Bypass Grafting
Coronary artery bypass grafting (CABG) is the most common type of heart surgery. CABG improves blood flow to the heart. Surgeons use CABG to treat people who have severe coronary heart disease (CHD).
CHD is a disease in which a waxy substance called plaque (plak) builds up inside the coronary arteries. These arteries supply oxygen-rich blood to your heart.
Over time, plaque can harden or rupture (break open). Hardened plaque narrows the coronary arteries and reduces the flow of oxygen-rich blood to the heart. This can cause chest pain or discomfort called angina (an-JI-nuh or AN-juh-nuh).
If the plaque ruptures, a blood clot can form on its surface. A large blood clot can mostly or completely block blood flow through a coronary artery. This is the most common cause of a heart attack. Over time, ruptured plaque also hardens and narrows the coronary arteries.
During CABG, a healthy artery or vein from the body is connected, or grafted, to the blocked coronary artery. The grafted artery or vein bypasses (that is, goes around) the blocked portion of the coronary artery. This creates a new path for oxygen-rich blood to flow to the heart muscle.
Surgeons can bypass multiple blocked coronary arteries during one surgery.
CABG isn't the only treatment for CHD. A nonsurgical procedure that opens blocked or narrow coronary arteries is percutaneous coronary intervention (PCI), also known as coronary angioplasty.
During PCI, a thin, flexible tube with a balloon at its tip is threaded through a blood vessel to the narrow or blocked coronary artery. Once in place, the balloon is inflated to push the plaque against the artery wall. This restores blood flow through the artery.
During PCI, a stent might be placed in the coronary artery to help keep it open. A stent is a small mesh tube that supports the inner artery wall.
If both CABG and PCI are options, your doctor can help you decide which treatment is right for you.
. Transmyocardial Laser Revascularization
Transmyocardial (tranz-mi-o-KAR-de-al) laser revascularization (re-VAS-kyu-lar-ih-ZA-shun), or TMR, is surgery used to treat angina.
TMR is most often used when no other treatments work. For example, if you've already had one CABG procedure and can't have another one, TMR might be an option. For some people, TMR is combined with CABG.
If TMR is done alone, the procedure may be performed through a small opening in the chest.
During TMR, a surgeon uses lasers to make small channels through the heart muscle and into the heart's lower left chamber (the left ventricle).
It isn't fully known how TMR relieves angina. The surgery may help the heart grow tiny new blood vessels. Oxygen-rich blood may flow through these vessels into the heart muscle, which could relieve angina.
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. Heart Valve Repair or Replacement
For the heart to work well, blood must flow in only one direction. The heart's valves make this possible. Healthy valves open and close in a precise way as the heart pumps blood.
Each valve has a set of flaps called leaflets. The leaflets open to allow blood to pass from one heart chamber into another or into the arteries. Then the leaflets close tightly to stop blood from flowing backward.
Heart surgery is used to fix leaflets that don't open as wide as they should. This can happen if they become thick or stiff or fuse together. As a result, not enough blood flows through the valve.
Heart surgery also is used to fix leaflets that don't close tightly. This problem can cause blood to leak back into the heart chambers, rather than only moving forward into the arteries as it should.
To fix these problems, surgeons either repair the valve or replace it with a man-made or biological valve. Biological valves are made from pig, cow, or human heart tissue and may have man-made parts as well.
To repair a mitral (MI-trul) or pulmonary (PULL-mun-ary) valve that's too narrow, a cardiologist (heart specialist) will insert a catheter (a thin, flexible tube) through a large blood vessel and guide it to the heart.
The cardiologist will place the end of the catheter inside the narrow valve. He or she will inflate and deflate a small balloon at the tip of the catheter. This widens the valve, allowing more blood to flow through it. This approach is less invasive than open-heart surgery.
Researchers also are testing new ways to use catheters in other types of valve surgeries. For example, catheters might be used to place clips on the mitral valve leaflets to hold them in place.
Catheters also might be used to replace faulty aortic valves. For this procedure, the catheter usually is inserted into an artery in the groin (upper thigh) and threaded to the heart.
In some cases, surgeons might make a small cut in the chest and left ventricle (the lower left heart chamber). They will thread the catheter into the heart through the small opening.
The catheter has a deflated balloon at its tip with a folded replacement valve around it. The balloon is used to expand the new valve so it fits securely within the old valve.
Currently, surgery to replace the valve is the traditional treatment for reasonably healthy people. However, catheter procedures might be a safer option for patients who have conditions that make open-heart surgery very risky.
. Arrhythmia Treatment
An arrhythmia (ah-RITH-me-ah) is a problem with the rate or rhythm of the heartbeat. During an arrhythmia, the heart can beat too fast, too slow, or with an irregular rhythm.
Many arrhythmias are harmless, but some can be serious or even life threatening. If the heart rate is abnormal, the heart may not be able to pump enough blood to the body. Lack of blood flow can damage the brain, heart, and other organs.
Medicine usually is the first line of treatment for arrhythmias. If medicine doesn't work well, your doctor may recommend surgery. For example, surgery may be used to implant a pacemaker or an implantable cardioverter defibrillator (ICD).
A pacemaker is a small device that's placed under the skin of your chest or abdomen. Wires connect the pacemaker to your heart chambers. The device uses low-energy electrical pulses to control your heart rhythm. Most pacemakers have a sensor that starts the device only if your heart rhythm is abnormal.
An ICD is another small device that's placed under the skin of your chest or abdomen. This device also is connected to your heart with wires. An ICD checks your heartbeat for dangerous arrhythmias. If the device senses one, it sends an electric shock to your heart to restore a normal heart rhythm.
Another arrhythmia treatment is called maze surgery. For this surgery, the surgeon makes new paths for the heart's electrical signals to travel through. This type of surgery is used to treat atrial fibrillation, the most common type of serious arrhythmia.
Simpler, less invasive procedures also are used to treat atrial fibrillation. These procedures use high heat or intense cold to prevent abnormal electrical signals from moving through the heart.
. Aneurysm Repair
An aneurysm (AN-u-rism) is a balloon-like bulge in the wall of an artery or the heart muscle. This bulge can occur if the artery wall weakens. Pressure from blood moving through the artery or heart causes the weak area to bulge.
Over time, an aneurysm can grow and burst, causing dangerous, often fatal bleeding inside the body. Aneurysms also can develop a split in one or more layers of the artery wall. The split causes bleeding into and along the layers of the artery wall.
Aneurysms in the heart most often occur in the heart's lower left chamber (the left ventricle). Repairing an aneurysm involves surgery to replace the weak section of the artery or heart wall with a patch or graft.
. Heart Transplant
A heart transplant is surgery to remove a person's diseased heart and replace it with a healthy heart from a deceased donor. Most heart transplants are done on patients who have end-stage heart failure.
Heart failure is a condition in which the heart is damaged or weak. As a result, it can't pump enough blood to meet the body's needs. "End-stage" means the condition is so severe that all treatments, other than heart transplant, have failed.
Patients on the waiting list for a donor heart receive ongoing treatment for heart failure and other medical conditions. Ventricular assist devices (VADs) or total artificial hearts (TAHs) might be used to treat these patients.
. Surgery to Place Ventricular Assist Devices or Total Artificial Hearts
A VAD is a mechanical pump that is used to support heart function and blood flow in people who have weak hearts.
Your doctor may recommend a VAD if you have heart failure that isn't responding to treatment or if you're waiting for a heart transplant. You can use a VAD for a short time or for months or years, depending on your situation.
A TAH is a device that replaces the two lower chambers of the heart (the ventricles). You may benefit from a TAH if both of your ventricles don't work well due to end-stage heart failure.
Placing either device requires open-heart surgery.
Surgeons can use different approaches to operate on the heart, including open-heart surgery, off-pump heart surgery, and minimally invasive heart surgery.
The surgical approach will depend on the patient's heart problem, general health, and other factors.
. Open-Heart Surgery
Open-heart surgery is any kind of surgery in which a surgeon makes a large incision (cut) in the chest to open the rib cage and operate on the heart. "Open" refers to the chest, not the heart. Depending on the type of surgery, the surgeon also may open the heart.
Once the heart is exposed, the patient is connected to a heart-lung bypass machine. The machine takes over the heart's pumping action and moves blood away from the heart. This allows the surgeon to operate on a heart that isn't beating and that doesn't have blood flowing through it.
Open-heart surgery is used to do CABG, repair or replace heart valves, treat atrial fibrillation, do heart transplants, and place VADs and TAHs.
. Off-Pump Heart Surgery
Surgeons also use off-pump, or beating heart, surgery to do CABG. This approach is like traditional open-heart surgery because the chest bone is opened to access the heart. However, the heart isn't stopped, and a heart-lung bypass machine isn't used.
Off-pump heart surgery isn't right for all patients. Work with your doctor to decide whether this type of surgery is an option for you. Your doctor will carefully consider your heart problem, age, overall health, and other factors that may affect the surgery.
. Minimally Invasive Heart Surgery
For minimally invasive heart surgery, a surgeon makes small incisions (cuts) in the side of the chest between the ribs. This type of surgery may or may not use a heart-lung bypass machine.
Minimally invasive heart surgery is used to do some bypass and maze surgeries. It's also used to repair or replace heart valves, insert pacemakers or ICDs, or take a vein or artery from the body to use as a bypass graft for CABG.
One type of minimally invasive heart surgery that is becoming more common is robotic-assisted surgery. For this surgery, a surgeon uses a computer to control surgical tools on thin robotic arms.
The tools are inserted through small incisions in the chest. This allows the surgeon to do complex and highly precise surgery. The surgeon always is in total control of the robotic arms; they don't move on their own.
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What to expect after Heart Surgery
Recovery in the Hospital
You may spend a day or more in the hospital's intensive care unit (ICU), depending on the type of heart surgery you have. An intravenous (IV) needle might be inserted in a blood vessel in your arm or chest to give you fluids until you're ready to drink on your own.
Your health care team may give you extra oxygen through a face mask or nasal prongs that fit just inside your nose. They will remove the mask or prongs when you no longer need them.
When you leave the ICU, you'll be moved to another part of the hospital for several days before you go home. While you're in the hospital, doctors and nurses will closely watch your heart rate, blood pressure, breathing, and incision site(s).
Recovery at Home
People respond differently to heart surgery. Your recovery at home will depend on what kind of heart problem and surgery you had. Your doctor will tell you how to:
. Care for your healing incision(s)
. Recognize signs of infection or other complications
. Cope with the after-effects of surgery
You also will get information about follow-up appointments, medicines, and situations when you should call your doctor right away.
After-effects of heart surgery are normal. They may include muscle pain, chest pain, or swelling (especially if you have an incision in your leg from coronary artery bypass grafting, or CABG).
Other after-effects may include loss of appetite, problems sleeping, constipation, and mood swings and depression. After-effects usually go away over time.
Recovery time after heart surgery depends on the type of surgery you had, your overall health before the surgery, and any complications from the surgery.
Your doctor will let you know when you can go back to your daily routine, such as working, driving, and physical activity.
Ongoing care after your surgery will include checkups with your doctor. During these visits, you may have blood tests, an EKG (electrocardiogram), echocardiography, or a stress test. These tests will show how your heart is working after the surgery.
After some types of heart surgery, you'll need to take a blood-thinning medicine. Your doctor will do routine tests to make sure you're getting the right amount of medicine.
Your doctor also may recommend lifestyle changes and medicines to help you stay healthy. Lifestyle changes may include quitting smoking, changing your diet, being physically active, and reducing and managing stress.
Your doctor also may refer you to cardiac rehabilitation (rehab). Cardiac rehab is a medically supervised program that helps improve the health and well-being of people who have heart problems.
Cardiac rehab includes exercise training, education on heart healthy living, and counseling to reduce stress and help you recover. Your doctor can tell you where to find a cardiac rehab program near your home.
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