Heart Surgery Overview

Heart surgery is done to correct problems with the heart. More than half a million heart surgeries are done each year in the United States for many heart problems.

Heart surgery is used for both children and adults. This article discusses heart surgery for adults. For more information about heart surgery for children, go to the Diseases and Conditions Index (DCI) articles about congenital heart defects, holes in the heart, and tetralogy of Fallot.

Overview

The most common type of heart surgery for adults is coronary artery bypass grafting (CABG). During CABG, surgeons use healthy arteries or veins taken from another part of the body to bypass (that is, go around) blocked heart arteries. CABG relieves chest pain and reduces the risk of heart attack.

Heart surgery also is done to:

• Repair or replace valves that control the direction of 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

Traditional heart surgery, often called open-heart surgery, is done by opening the chest wall to operate on the heart. Surgeons cut through the patient's breastbone (or just the upper part of it) to open the chest.  

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 surgeons to operate on a heart that isn't beating and that doesn't have blood flowing through it.

Another type of heart surgery is called off-pump, or beating heart, surgery. It's like traditional open-heart surgery, but it doesn't use a heart-lung bypass machine. Off-pump heart surgery is limited to CABG.

Many heart surgeries can now be done through small incisions (cuts) between the ribs. This is called minimally invasive heart surgery. This type of heart surgery may or may not use a heart-lung bypass machine.

These nontraditional methods of heart surgery (off-pump and minimally invasive) may reduce risks and speed up recovery time. Studies are under way to compare these types of heart surgery with traditional open-heart surgery. The results of these studies will help doctors decide the best surgery to use for each patient.

Outlook

The results of heart surgery in adults often are excellent. Heart surgery can reduce symptoms, improve quality of life, and increase lifespan.

To understand heart surgery, it's helpful to know how a normal heart works. Go to the DCI article on How the Heart Works for more information.

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. This surgery is used for people who have severe coronary heart disease (CHD), also called coronary artery disease.

In CHD, a fatty substance called plaque (plak) builds up inside your coronary (heart) arteries. Plaque narrows the arteries and limits blood flow to your heart muscle. CHD can cause angina (an-JI-nuh or AN-juh-nuh), shortness of breath, and heart attack. (Angina is chest pain or discomfort, which often occurs with physical activity.)  

During CABG, a surgeon takes a vein or an artery from your chest, leg, or another part of your body and connects, or grafts, it to the blocked artery.

The grafted artery bypasses (that is, goes around) the blockage. This allows oxygen-rich blood to reach the heart muscle. Surgeons can bypass multiple blocked coronary arteries during one surgery.

Coronary Artery Bypass Grafting

 

Figure A shows the location of the heart. Figure B shows how vein and artery bypass grafts are attached to the heart.

Angioplasty (AN-jee-oh-plas-tee) is another treatment for CHD. This procedure opens blocked or narrowed coronary arteries.

A thin, flexible tube with a balloon or other device on the end is threaded through a blood vessel to the narrowed or blocked coronary artery. Once in place, the balloon is inflated to compress the plaque against the wall of the artery. This restores blood flow through the artery.

During angioplasty, your doctor may put a small mesh tube called a stent in the artery. The stent supports the artery wall and reduces the chance of the artery becoming blocked again.

If both CABG and angioplasty 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-i-ZA-shun), or TMR, is a surgery used to treat angina when no other treatments work.

For example, if you've already had one CABG procedure and can't have another one, TMR may be an option. This type of heart surgery isn't common.

During TMR, a surgeon uses lasers to make channels in the heart muscle. These channels allow oxygen-rich blood to flow from a heart chamber directly into the heart muscle.

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 back into the chamber from which it came.

Heart surgery is done 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 into the artery.

Heart surgery also is done to fix leaflets that don't close tightly. This problem can cause blood to leak backward 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. Replacement valves are taken from animals or made from human tissue or man-made materials.

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 narrowed valve. He or she will rapidly inflate and deflate a small balloon at the tip of the catheter. This widens the valve, allowing blood to flow through it to the artery. 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 may be used to place clips on the mitral valve leaflets to hold them in place.

Catheters also may 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.

At the end of the catheter is a deflated balloon with a folded replacement valve around it. Once the replacement valve is properly placed, the balloon is used to expand the new valve so it fits securely within the old valve.

Catheter procedures may be a safer option for patients who have conditions that make open-heart surgery very risky. Only a few medical centers are doing these experimental procedures. However, the results may lead to improved heart surgery approaches.

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.

Most arrhythmias are harmless, but some can be serious or even life threatening. When 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.

Arrhythmias usually are treated with medicine first. If medicine doesn't work well, you may need surgery. For example, your doctor may use surgery to implant apacemaker 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 pacemaker sends electrical signals through the wires to control your heart rhythm. Most pacemakers have a sensor that activates the device only when your heart rhythm is abnormal.

An ICD is another small device that's placed in your chest or abdomen. This device also is connected to your heart with wires. An ICD checks your heartbeat for dangerous arrhythmias. If it senses one, it sends an electric shock to your heart to restore a normal heart rhythm.

Another type of surgery for arrhythmia 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. This helps the heart's electrical signals move through the proper pathway.

Aneurysm Repair

An aneurysm (AN-u-rism) is an abnormal bulge or "ballooning" in the wall of an artery or the heart muscle. This bulge happens when the 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 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. Your doctor may recommend a heart transplant if your heart is so damaged or weak that it can't pump enough blood to meet your body's needs. This condition is called heart failure.

This type of surgery is a life-saving measure that's used when medical treatment and less drastic surgery 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) may be used to treat these patients.

Ventricular Assist Devices

VADs are mechanical pumps that are used to support heart function and blood flow in people who have weakened 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.

Surgical Approaches

Depending on a patient's heart problem, general health, and other factors, he or she can have open-heart surgery or minimally invasive heart surgery.

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.

Open-heart surgery is used to bypass blocked arteries in the heart, repair or replace heart valves, treat atrial fibrillation, and do heart transplants.

Off-Pump Heart Surgery

Increasing numbers of surgeons have started to use off-pump, or beating heart, surgery to do CABG. This approach is like traditional open-heart surgery, but surgeons don't use a heart-lung bypass machine.

Off-pump heart surgery isn't right for all patients. Work with your doctor to decide whether this type of surgery may benefit 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 for some CABG and maze procedures. It's also used to repair or replace heart valves and insert pacemakers or ICDs.

One type of minimally invasive heart surgery that's still being developed 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.

Who Needs Heart Surgery?

Heart surgery is used to treat people who have certain heart diseases and conditions. If other treatments-such as lifestyle changes, medicines, and medical procedures-haven't worked or can't be used, heart surgery may be an option.

Heart surgery is used to treat heart failure and coronary heart disease. It's also used to fix heart valves that don't work well, to control heartbeats, and to replace a damaged heart with a healthy one.

Specialists Involved

Your primary care doctor, a cardiologist, and a cardiothoracic (KAR-de-o-tho-RAS-ik) 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 test results with you, and you'll help make decisions about the surgery.

Medical Evaluation

Your doctors will talk with you about:

• The kind of heart problem you have, the symptoms it's causing, and how long you've had symptoms
• Your history and past treatment of heart problems, including surgeries, procedures, and medicines
• Your family's history of heart problems
• Your history of other health problems and conditions, such as diabetes orhigh 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.

Diagnostic Tests

Diagnostic 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 simple, painless test that records the heart's electrical activity. This test is used to help detect and locate the source of heart problems.

A technician attaches sticky patches, called electrodes, to the skin of your chest, arms, and legs. The electrodes are attached with wires to a machine that records your heart's electrical signals.

An EKG shows how fast your heart is beating and whether its rhythm is steady or irregular. The test also shows where in your heart the electrical activity starts, and whether it's traveling through your heart in a normal way.

An EKG also can detect heart injury and whether your heart muscle is getting enough oxygen.

Stress Test

Some heart problems are easier to diagnose when your heart is working hard and beating fast. During stress testing, you exercise (or are given medicine if you're unable to exercise) to make your heart work hard and beat fast.

As part of the test, your blood pressure is checked and an EKG is done. Other heart tests also may be done.

Echocardiography

Echocardiography is a painless, noninvasive test. "Noninvasive" means that no surgery is done and no instruments are inserted into your body.

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 properly, and previous injury to your heart muscle caused by poor blood flow.

Coronary Angiography

Coronary angiography (an-jee-OG-ra-fee) uses contrast dye to make your coronary arteries visible on an x-ray image (called an angiogram). This test shows the location and severity of blockages in the blood vessels.

To get the dye to your coronary arteries, a procedure called cardiac catheterization is used. Cardiologists usually do cardiac catheterizations in a hospital. You're awake during the procedure, and it usually causes little to no pain.

During this procedure, a thin, flexible tube called a catheter is passed through an artery in your arm, groin (upper thigh), or neck and threaded to your heart. The dye is injected into your bloodstream through the tip of the catheter.

Special x rays are taken while the dye is flowing through your coronary arteries.

Aortogram

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 provides a picture of the organs and structures inside your chest, including the 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 travels through your blood vessels, which helps highlight them on the x-ray pictures.

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

Cardiac magnetic resonance imaging (MRI) is a safe, noninvasive test that uses magnets and radio waves to create pictures of your organs and tissues.

Cardiac MRI uses a computer to create images of your heart as it's 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 find aneurysms and determine their size and exact location.

What To Expect Before Heart Surgery

Many types of heart surgery are used to fix heart problems. The type you need depends on your situation. 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. Others are diagnosed with blocked coronary arteries and are admitted to the hospital right away for surgery.

If you're having a planned surgery, you may be admitted to the hospital the afternoon or morning before your 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 also may need to have some tests, 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.

Hair near the incision site may be shaved. Your skin may 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 feel no pain during the surgery.

What To Expect During Heart Surgery

Heart surgery is done in a hospital. A team of experts is involved. Cardiothoracic surgeons perform the surgery with a team of other doctors and nurses who assist.

The length of time for the surgery depends on the type of surgery. CABG, the most common type of heart surgery, usually takes 3 to 5 hours.

Traditional Open-Heart Surgery

For this type of surgery, you're given medicine to make you fall asleep. A doctor checks your heartbeat, blood pressure, oxygen levels, and breathing during the surgery. A breathing tube is placed in your lungs through your throat and connected to a ventilator (a machine that supports breathing).

A surgeon makes a 6- to 8-inch incision (cut) down the center of your chest wall. Your breastbone is cut and your rib cage is opened so that the surgeon can get to your heart.

You're given medicine to thin your blood and keep it from clotting. A heart-lung bypass machine is connected to your heart. The machine takes over your heart's pumping action and moves blood away from your heart.

A specialist oversees the heart-lung bypass machine. The machine allows the surgeon to operate on a heart that isn't beating and that doesn't have blood flowing through it.

Heart-Lung Bypass Machine

The illustration shows how a heart-lung bypass machine works during surgery.

You're given medicines to stop your heartbeat once you're connected to the heart-lung bypass machine. A tube is placed in your heart to drain blood to the machine.

The machine removes carbon dioxide (a waste product) from your blood, adds oxygen, and then pumps the blood back into your body. Tubes are inserted into your chest to drain fluid.

Once the bypass machine begins to work, the surgeon does the surgery to repair your heart problem.

After the surgery is done, blood flow to your heart is restored. Usually, the heart starts beating again on its own. In some cases, mild electric shocks are used to restart the heart.

Once the heart has started beating again, the tubes are removed and the heart-lung bypass machine is stopped. You're given medicine to allow your blood to clot again.

The surgeon uses wires to close your breastbone. The wires stay in your body permanently. After your breastbone heals, it will be as strong as it was before the surgery.

Stitches or staples are used to close the skin incision. Your breathing tube is removed when you're able to breathe without it.

Off-Pump Heart Surgery

This type of surgery is the same as traditional open-heart surgery, except you aren't connected to a heart-lung bypass machine. Instead, your heart is steadied with a mechanical device while the surgeon works on it. Your heart continues to pump blood to your body.

Minimally Invasive Heart Surgery

For this type of heart surgery, the surgeon makes small incisions in the side of your chest between the ribs. These incisions can be as small as 2 to 3 inches. Then the surgeon inserts surgical tools through these small incisions.

A tool with a small video camera at the tip also is inserted through an incision. This allows the surgeon to see inside your body.

Some types of minimally invasive heart surgery use a heart-lung bypass machine; other types do not.

What To Expect After Heart Surgery

Recovery in the Hospital

Depending on the type of heart surgery, you may spend a day or more in the hospital's intensive care unit (ICU). You may have an intravenous (IV) needle 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. The mask or prongs are removed 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. The entire time you're at the hospital, doctors and nurses will closely watch your heart rate, blood pressure, breathing, vital signs, and incision site(s).

Recovery at Home

Each person responds 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 incisions
• Recognize signs of infection or other complications
• Cope with after-effects of surgery

You also will get information about followup 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 varies for different types of heart surgery. Full recovery from traditional open-heart CABG may take 6 to 12 weeks or more. Less recovery time is needed for off-pump heart surgery and minimally invasive heart 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

Ongoing care after your surgery may include periodic 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.

Some types of heart surgery require you 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, making changes to your diet, being physically active, and reducing and managing stress.

You doctor may refer you to a cardiac rehabilitation (rehab) program. Cardiac rehab includes counseling, education, and exercise training to help you recover. The program also will help you learn how to make choices that can lower your risk for future heart problems.

What Are the Risks of Heart Surgery?

Heart surgery has risks, even though its results often are excellent. Risks include:

• Bleeding.
• Infection, fever, swelling, and other signs of inflammation.
• A reaction to the medicine used to temporarily put you to sleep during surgery.
• Arrhythmias (irregular heartbeats).
• Memory loss and problems concentrating or thinking clearly.
• Damage to tissues in the heart, kidneys, and lungs.
• Strokes, 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.)

In general, the risks of heart surgery are higher for people who:

• Are older than 70
• Have had previous heart surgeries
• Have diseases or conditions such as high blood pressure, diabetes, kidney disease, lung disease, or peripheral arterial disease

The use of a heart-lung bypass machine increases the risk of blood clots forming in your blood vessels. Clots can travel to the brain or other parts of the body and block blood flow. This can cause a stroke or other problems.

Improvements to heart-lung bypass machines and heart surgery techniques are helping reduce the risk of blood clots.