Cardiac Surgery

Heart-related problems do not always require surgery. Sometimes they can be addressed with lifestyle changes, medications, or nonsurgical procedures. For example, catheter ablation uses energy to make small scars in your heart tissue to prevent abnormal electrical signals from moving through your heart. Coronary angioplasty is a minimally invasive procedure in which a stent is inserted into a narrowed or blocked coronary artery to hold it open. Nonetheless, surgery is often needed to address problems such as heart failure, plaque buildup that partially or totally blocks blood flow in a coronary artery, faulty heart valves, dilated or diseased major blood vessels (such as the aorta), and abnormal heart rhythms.

What are some types of cardiac surgery?

There are many types of heart surgery. The National Heart, Lung, and Blood Institute, which is part of the National Institutes of Health, lists the following as among the most common coronary surgical procedures.

1. Coronary artery bypass grafting (CABG). In CABG – the most common type of heart surgery – the surgeon takes a healthy artery or vein from elsewhere in your body and connects it to supply blood past the blocked coronary artery. The grafted artery or vein bypasses the blocked portion of the coronary artery, creating a new path for blood to flow to the heart muscle. Often, this is done for more than one coronary artery during the same surgery. CABG is sometimes referred to as heart bypass or coronary artery bypass surgery.

• Heart valve repair or replacement. Surgeons either repair the valve or replace it with an artificial valve or with a biological valve made from pig, cow, or human heart tissue. One repair option is to insert a catheter through a large blood vessel, guide it to the heart, and inflate and deflate a small balloon at the tip of the catheter to widen a narrow valve.

• Insertion of a pacemaker or an implantable cardioverter defibrillator (ICD). Medicine is usually the first treatment option for arrhythmia, a condition in which the heart beats too fast, too slow or with an irregular rhythm. If medication does not work, a surgeon may implant a pacemaker under the skin of the chest or abdomen, with wires that connect it to the heart chambers. The device uses electrical pulses to control the heart rhythm when a sensor detects that it is abnormal. An ICD works similarly, but it sends an electric shock to restore a normal rhythm when it detects a dangerous arrhythmia.

• Maze surgery. The surgeon creates a pattern of scar tissue within the upper chambers of the heart to redirect electrical signals along a controlled path to the lower heart chambers. The surgery blocks the stray electrical signals that cause atrial fibrillation — the most common type of serious arrhythmia.

• Aneurysm repair. A weak section of the artery or heart wall is replaced with a patch or graft to repair a balloon-like bulge in the artery or wall of the heart muscle.

• Heart transplant. The diseased heart is removed and replaced with a healthy heart from a deceased donor.

• Insertion of a ventricular assist device (VAD) or total artificial heart (TAH). A VAD is a mechanical pump that supports heart function and blood flow. A TAH replaces the two lower chambers of the heart.

In addition to these surgeries, a minimally invasive alternative to open-heart surgery that is becoming more common is transcatheter structural heart surgery. This involves guiding a long, thin, flexible tube called a catheter to your heart through blood vessels that can be accessed from the groin, thigh, abdomen, chest, neck, or collarbone. A small incision is necessary. This type of surgery includes transcatheter aortic valve implantation to replace a faulty aortic valve with a valve made from animal tissue, MitraClip placement for mitral valve abnormalities, and WATCHMAN placement for nonvalvular atrial fibrillation patients.

What are the risks?

Most heart surgeries are major surgeries. Although often successful, they do entail risks. The National Heart, Lung, and Blood Institute identifies some of these risks as:

• Bleeding
• Infection
• Reactions to anesthesia
• Damage to tissues in the heart, kidneys, liver, and lungs
• Stroke
• Death, especially for someone who is already very sick before surgery

The risk is higher if you have other diseases or conditions, such as diabetes, peripheral artery disease, or kidney or lung disease.

What is the role of the cardiac anesthesiologist?

A specially trained physician anesthesiologist, called a cardiac, cardiothoracic, or cardiovascular anesthesiologist, is involved in your care before, during, and after surgery.

• For nonemergency surgery, a cardiac anesthesiologist typically will meet with you before the operation to explain the anesthesia procedures, risks, and side effects. To help reduce your risk during surgery, the anesthesiologist will review your medical history and diagnostic tests, ask about prior reactions to anesthesia, and advise you on which of your medications you should stop or continue taking in the days leading up to the operation.
• The physician anesthesiologist’s role during cardiac surgery is extensive and goes beyond administering general anesthesia. The anesthesiologist intensively monitors the patient’s condition in various ways. This includes using special catheters in major blood vessels in the neck and chest.

• Monitoring often includes the use of an ultrasound probe to evaluate the heart valves and muscle function. The anesthesiologist will use this ultrasound technology (called transesophageal echocardiography, or TEE) to guide the surgeon during the procedure and to evaluate the success of the surgical repairs. TEE also can help determine the cause of emergency conditions such as low blood pressure or breathing difficulties.

• If your surgery requires the use of a heart-lung bypass machine, the anesthesiologist will administer a drug called heparin to prevent blood from clotting as it passes through the machine. The surgeon often will stop the heart from beating in order to perform the surgery. Once the surgeon has completed the operation, the anesthesiologist will provide medications or recommend other assistance to restart your heart and restore its role in supporting your blood circulation. This concept may sound scary, but the use of the heart-lung bypass machine is well established. As of 2013, it was estimated that more than 1 million cardiac operations were performed each year worldwide with the use of the device.

• After surgery, the anesthesiologist will monitor your recovery from the anesthesia and help direct your pain management. Physician anesthesiologists also provide care for patients in the intensive care unit following cardiac surgery, although this is not usually the same anesthesiologist who provided your care in the operating room.

How do I manage post-operative pain?

A cardiac anesthesiologist is also a pain management specialist for conditions related to surgery. Your anesthesiologist will talk to you about your options for managing post-operative pain. Before your surgery, the anesthesiologist may ask about your pain tolerance to help gauge how best to manage your post-operative pain, guiding decisions such as the proper narcotics dosage, the feasibility of nonnarcotic pain medication options, and the need for nerve blocks.

Although most heart surgeries are major surgeries, they are typically not a source of long-term pain. Even in the short term, the pain may be less severe than with operations on other areas of the body. Opioids are used when necessary, but there are many other pain management options, including:

• Nerve blocks
• Nonsteroidal anti-inflammatory drugs
• Acetaminophen
• Ketamine
• Lidocaine infusion

What is the recovery time?

Recovery time depends on the type of surgery you have, but for most types of heart surgery you are likely to spend a day or more in the hospital’s intensive care unit. Then you will be moved to another part of the hospital for several days until you go home.

The National Heart, Lung, and Blood Institute notes that the length of your recovery time at home will depend on the type of surgery you had, your overall health before the surgery, and whether you experienced any complications from surgery. For example, full recovery from a traditional coronary artery bypass may take six to 12 weeks or more.