Heart Surgery Explained: Procedures and Surgeries for Heart Conditions & Diseases
One in four U.S. deaths is caused by heart disease and this year, nearly 750,000 heart attacks will occur.
Based on these numbers, the need for advances in cardiovascular medicine is clear.
Historically, cardiac surgeries were not performed in the U.S. until half way through the 20th century. Though many doctors believed that surgical procedures might be effective in treating heart health prevailing cardiac experts remained against it. At the time, it was thought that a heart wound would be too afflictive and heart function would cease after a series of cuts and sutures. This stalled advanced treatment of heart conditions for years to come.
Eventually however, as heart disease emerged as the number one killer of Americans, science and research had to find a way to effectively treat heart patients through surgery.
Medical Procedures for Heart Disease
Depending on severity, heart patients may need a surgical procedure to treat coronary conditions effectively.
When is heart surgery performed?
Heart surgery may be performed for a number of reasons including:
- To implant a medical device
- To treat heart failure
- To treat coronary heart disease
- To repair heart valves
- To treat arrhythmia
- To replace the heart altogether
Types of Heart Surgery
Many types of surgical procedures are performed including:
Coronary Artery Bypass Grafting
The most common surgical procedure performed on heart patients is coronary artery bypass grafting (CABG). This effectively treats coronary heart disease in many cases.
Who gets coronary artery bypass grafting?
Coronary artery bypass grafting (CABG) may be used when blockages are severe and involve larger arteries. CABG is also an option for patients when other treatments such as coronary angioplasty are not viable.
How is coronary artery bypass grafting performed?
In CABG a healthy artery or vein essentially bypasses the blocked artery and is grafted to either heart tissue or a coronary artery. This allows blood to flow to the heart muscle freely. In the course of one surgery an 8-10-inch incision is made in the chest and surgeons can bypass several coronary artery blockages.
How long does coronary artery bypass grafting take?
A CABG procedure can last anywhere from 3-6 hours.
Once surgery is complete, the surgeon closes the breastbone using wire. This will remain in the body permanently.
Small titanium plates may be used instead to join the breastbone after the heart repair is complete. Patients who have had several surgeries or older patients may require this type of closure known as “sternal plating”.
Patients who undergo coronary artery bypass grafting may live without symptoms of coronary artery disease for up to 15 years.
Other Types of Heart surgery
About two-thirds of all angioplasties are performed during a serious cardiac event such as a heart attack, or escalating angina pain. The procedure takes about 20 minutes and can restore blood flow and reduce pain almost immediately. Angioplasty can lower the risk of having a second heart attack.
One-third of angioplasty patients undergo the procedure to reduce the risk of a heart attack. This is only performed, however, if the individual has serious symptoms and standard therapies such as medications are not successful.
Complications and Risks of Angioplasty Procedure
- Bleeding from the catheter insertion site
- Blood clots that can induce a minor heart attack or stroke during the procedure
What is coronary angioplasty?
A coronary angioplasty procedure is sometimes performed in order to open an artery to improve blood flow to the heart. Coronary arteries may become blocked due to a medical condition known as atherosclerosis. Atherosclerosis is caused by plaque build-up in the artery walls.
While plaque can build up in any artery of the body, when it occurs in coronary arteries it is referred to as coronary artery disease (CAD).
How does coronary angioplasty help?
Coronary angioplasty allows increased blood flow to the heart, which may help:
- Angina symptoms
- Shortness of breath
- Limit damage to the heart during a heart attack
- Save a life by opening blocked artery (arteries)
How common is the coronary angioplasty procedure?
Over 1 million Americans get coronary angioplasty each year.
Who gets coronary angioplasty?
While lifestyle changes such as eating a healthy diet, getting plenty of exercise, and quitting smoking are the first line of defense against heart disease, sometimes other treatment options must be considered.
When medication is unsuccessful in treating coronary artery disease, a coronary angioplasty procedure may be needed.
Coronary angioplasty can be performed in an emergency setting or as a preventive measure to reduce the risk of a heart attack.
What is the medical term for an angioplasty procedure?
An angioplasty procedure with stent may also be referred to as percutaneous coronary intervention (PCI).
How does angioplasty work?
A thin tube known as a catheter is threaded through an artery in the femur or wrist until it reaches the blocked coronary artery. A small balloon attached to the end of the catheter is inflated to expand the artery and allow for blood flow. The surgeon will place a stent, or small metal mesh coil in the artery to keep the artery open. Tissue will begin to grow around the stent and medications including antiplatelets may be given to reduce the stickiness of blood platelets that could cause blood clots in the stent.
Two types of stents exist. These are either bare metal stents (BMS) or drug-eluting stents (DES). DES stents release a drug that prevents cells within the artery from growing and spreading. This helps stop future blockage of blood flow within the artery itself.
Transmyocardial Laser Revascularization—TMR
This type of heart surgery relieves angina symptoms when other treatments for the condition have failed. TMR may be combined with CABG or offered if CABG has already been performed. In TMR a surgeon makes small laser cuts into the lower left chamber of the heart, which may help new blood vessels to grow. This allows additional blood flow through the heart and angina pain relief.
This procedure may also be used to treat severe angina in individuals who are not strong candidates for other procedures such as bypass surgery alone or angioplasty.
An angioplasty-like procedure is performed with a special catheter fitted with a laser tip. The pulsating light beam breaks up plaque in the coronary arteries, restoring blood flow once again.
An atherectomy is performed to remove dangerous plaque build up in the coronary arteries. Much like an angioplasty, a catheter with a rotating shaver tip cuts away plaque to restore blood flow. This procedure may be used on coronary arteries to reduce the risk of a heart attack or on carotid arteries that lead to the brain to help prevent the risk of strokes.
A cardiomyoplasty may be attempted in patients with weak hearts that no longer pump blood efficiently. The experimental procedure utilizes skeletal muscles that are surgically removed from the back or abdomen. When surgically “wrapped” around the heart and stimulated with a pacemaker-like device, the pumping motion of the heart may become stronger.
Repair or Replacement of Heart Valves
Heart valves ensure that blood flows in only one direction through the muscle. Sometimes flaps on heart valves don’t open as widely as necessary, however, or don’t completely close. They may also become thick, stiff or fused together which inhibits proper blood flow.
The heart has four valves, each with a particular function to move blood through the cardiovascular system.
The mitral and tricuspid valves, manage the flow of blood from the atria to the ventricles.
The aortic and pulmonary valves, manage blood flow exiting the ventricles.
Heart valve disease can interrupt proper blood flow from one chamber to the next, or cause blood to leak back into the previous chamber. Either way, the heart must work harder in an attempt to keep blood flow adequate for full body function.
Valves may be replaced with animal tissue (valves) combined with man-made materials.
Surgically Treating Arrhythmia
If the rhythm of the heartbeat is not normal, the heart may sometimes fail to pump the right amount of blood. This could result in brain, heart, or other organ damage. If other non-surgical treatments have been ineffective, a pacemaker or implantable cardioverter-defibrillator (ICD) may be placed under the skin of the abdomen or chest to regulate the heart.
Open-heart Surgery for Device Placement
Ventricular Assist Devices
Ventricular Assist Devices (VAD’s) involve a mechanical pump used to increase heart function while in heart failure. Some individuals use this option while awaiting a heart transplant or if the heart does not respond well to medication. Ventricular Assist Devices can last for several months, sometimes years.
Total Artificial Hearts
Total Artificial Hearts (TAF) replace the ventricles, or lower chambers of the heart. These may be effective if ventricles fail to function properly due to end-stage heart failure.
Artificial Pacemaker Surgery
Some individuals suffer from irregular heart activity that causes an abnormal heartbeat. A pacemaker may be implanted under chest skin to regulate heart rhythms. Mild electric pulses stimulate the heart muscle to pump blood more efficiently. Tiny wires connected to the pacemaker device are attached to the heart chambers. Pacemakers are designed to operate for several years with the same battery, sometimes as long as 10 years. Artificial pacemaker surgery is usually performed quickly and patients are usually released from the hospital within one day. In some cases, patients can return home the same day. Most people can resume a modified routine after a few days, but must refrain from heavy lifting, or strenuous activity for awhile.
Heart Surgery for Repair of an Aneurysm
Sometimes an artery wall (or the heart muscle itself) becomes weak in certain areas and bulge with the flow of blood. The artery can also split causing bleeding into the artery walls. This type of heart surgery requires a procedure to patch or graft the weak section of the artery or heart wall.
In the end stages of heart failure a heart transplant may be the only option left to save the life of the patient. In this case, the heart is too diseased or too weak to pump enough blood to support the body and brain and all other treatment methods have been unsuccessful. Despite the great need for donor hearts and heart transplantations in the United States, only about 2,000 are performed each year however.
While waiting for a suitable heart, a ventricular assist device (VAD) or total artificial heart (TAH) may be implanted to assist heart pump function or to replace lower ventricles. Both procedures require open-heart surgery.
Approaches to Heart Surgery
There are several approaches to heart surgery depending on the severity of the heart problem and the age and health of the patient.
Open-Heart Surgery—In this case, the surgeon cuts into the chest to expose and open the ribcage. This allows complete access to the heart. A heart-lung bypass machine is connected to the patient to allow blood to flow away from the heart, so it can be stopped. Here coronary arteries, muscles, or heart valves can be repaired.
Off-Pump Heart Surgery—The chest cavity is opened to allow access to the heart, though the heart is still beating and no heart-lung bypass machine is used. This surgical approach may be used to perform a CABG procedure.
Minimally Invasive Heart Surgery— Many surgeries can now be performed with small incisions. These are made between the ribs, in the side of the chest and a heart-lung bypass machine may or may not be used. Some bypass surgeries, valve replacements and device placements may allow for this minimally invasive approach. Robotic-assisted surgery is sometimes performed in these cases as well.
How is Minimally invasive Open-heart Surgery performed?
Generally the surgeon will make a 3-5 inch incision on the left side of the chest to reach the heart. Then, muscles are pushed apart and cartilage from the rib removed. Although the heart-lung machine will not be used, medication to slow the heart rate is administered. A drainage tube from the chest will be used for a couple of days post surgery.
General Risks of Coronary Artery Bypass Surgery
- Arrhythmia problems
- Infection of chest wound
- Low grade fever
- Pain at incision site
Minimally invasive surgery lowers the risk of many aftereffects, however, some risk is still involved.
Following the procedure patients could experience:
- Blood clots—Blood clots may form in the legs, which could potentially move through the blood to the lungs.
- Loss of blood
- Difficulties Breathing
- Heart attack/stroke
- Lung, chest or urinary tract infections
- Temporary/permanent brain injury
Advantages to Minimally Invasive Heart Surgery
Individuals who have not been placed on a heart and lung machine report fewer mental difficulties after surgery. Patients experience decreased fuzzy thinking, memory loss, or loss of mental clarity than those who’ve undergone more traditional invasive coronary procedures.
What to Expect with Heart Surgery
Often, for a short period preceding surgery, regular medications that inhibit blood clotting must be stopped. This is to avoid hemorrhage during surgery.
Post Open-heart Surgery
Chest tubes that drain fluid around the heart will be attached to the wound area for several days.
The incision site must be kept clean and as sterile as possible to avoid the risk of infection.
Pain following the procedure must be effectively managed to not only make the patient comfortable, but to facilitate the healing process. Relief from pain lowers the risk of developing blood clots and pneumonia post surgery.
Muscle pain, throat pain, and pain surrounding the incision site, are all common following an open-heart surgical procedure.
Mental and Psychological Effects of Heart Surgery
Some patients may have temporary deficits in cognitive function following surgery. This generally only lasts for a short period of weeks or months. Some individuals experience anxiety or depression following heart surgery and may benefit from therapy or counseling to help manage symptoms.
Non-surgical Heart Procedures
A defibrillator may be used to restore heart function during a cardiac arrest. Electrified paddles are placed on the patient’s chest and activated in an attempt to stimulate the heart beating once again. In some cases a defibrillator may be used in a non-emergency situation to regulate heart rhythm issues.
Thrombolytic therapy may be necessary to clear a coronary artery of a blood clot. Medication is administered through an IV drip to dissolve the mass. Once the clot breaks up, blood flow to the heart immediately improves.
This may be given to patients who have suffered a heart attack or stroke within the past few hours. The quicker the drug is administered after the initial event, the better the treatment outcome. Thrombolytic therapy should not be used on patients who have/are:
- Recent head trauma
- Issues bleeding
- Bleeding ulcers
- Had surgery that’s recent
- On other medications to reduce blood thickness
- Physical trauma
- Very high blood pressure 
Sometimes thrombolysis is not performed and a coronary angioplasty or coronary artery bypass graft is necessary to provide adequate blood flow through the coronary arteries.
Temperature Controlled Procedure
Some less invasive procedures use high heat or intense cold to block errant electrical signals moving through the heart.
Radiofrequency ablation may be performed to treat certain heart arrhythmias. The procedure involves a guided catheter threaded through veins to the heart, using a fluoroscopy (imaging technology). The catheter fitted with an electrode tip transmits radiofrequency energy that kills specific cells in the heart muscle that previously caused irregular heart rhythms.
Heart Surgery—Progress and Technology
New techniques and technologies continue to dominate the field of heart health and treatment.
“TandemLife pump and oxygenator” supports the heart and lungs without the use of a breathing machine. Oxygen is delivered to all vital organs and limbs, as blood pressure is kept constant in the body. Patients are sedated during heart procedures supported by TandemLife systems, yet can communicate easily upon waking from surgery.
New Catheter for Valve Replacement
While traditional valve replacement surgery is still the standard in many areas, some surgeons have experimented with catheters to replace heart valves. With the new procedure, a tiny catheter is inserted through an artery to the heart. A deflated balloon at the catheter tip holds a replacement valve as well. By inflating the balloon, the replacement valve is now fitted within the old valve and ready to work controlling blood flow to and from the heart.
Maze Surgery for the Heart
Maze surgery may be effective in treating certain kinds of arrhythmia. In the procedure, surgeons create new signal pathways for electrical impulses to treat atrial fibrillation.
Robotic-Assisted Heart Surgery
Many surgeries may be performed with the use of robot technology. In one type of minimally invasive heart surgery, a small incision is made in the chest and thin robotic arms control surgical tools by computer. This allows for great precision during complex surgical procedures on patients.
Human Heart Support through Animal Organs
Although the use of animal hearts for transplantation in humans has yet to be successful, research into genetic alteration of some species, such as pigs holds great promise for the future. For some individuals with end-stage heart failure, an animal organ may one day provide the necessary support for final treatment and a longer life.
As we move forward into the future, it is clear that the need for alternative heart procedures and surgeries is crucial. With approximately 5 million people suffering with end stage heart failure every year (for which there is no cure other than a heart transplant) and a half-million new patients diagnosed annually, advances in heart treatment are necessary.
1Common Medical Procedures for Heart Conditions>, www.healthywa.wa.gov.au/Articles/A_E/Common-medical-procedures-for-heart-conditions.
2“Angioplasty and Stent Placement for the Heart.” Angioplasty and Stent Placement for the Heart – Health Encyclopedia – University of Rochester Medical Center, www.urmc.rochester.edu/encyclopedia/content.aspx?contenttypeid=92&contentid=P07981.
3“Cardiac Procedures and Surgeries.” Www.heart.org, www.heart.org/en/health-topics/heart-attack/treatment-of-a-heart-attack/cardiac-procedures-and-surgeries.
4“Cardiologist Uses New Heart/Lung Technology in Cath Lab to Avoid Open-Heart Surgery for High-Risk Patient.” Cardiologist Uses New Heart/Lung Technology in Cath Lab to Avoid Open-Heart Surgery for High-Risk Patient | Sarver Heart Center, heart.arizona.edu/heart-health/minimally-invasive-procedures/cardiologist-uses-new-heartlung-technology-cath-lab-avoid.
5“Coronary Angioplasty and Stenting.” Coronary Angioplasty and Stenting | Cardiac Surgery | Michigan Medicine | University of Michigan, medicine.umich.edu/dept/cardiac-surgery/patient-information/adult-cardiac-surgery/adult-conditions-treatments/coronary-angioplasty-stenting.
6“Coronary Artery Bypass Grafting.” National Heart Lung and Blood Institute, U.S. Department of Health and Human Services, www.nhlbi.nih.gov/health-topics/coronary-artery-bypass-grafting.
7Harvard Health Publishing. “Understanding Angioplasty: When You Need It and When You May Not.” Harvard Health, www.health.harvard.edu/heart-health/understanding-angioplasty-when-you-need-it-and-when-you-may-not.
8“Heart Attack Facts & Statistics.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, www.cdc.gov/heartdisease/heart_attack.htm.
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Angioplasty and Chest Pain:
My 43 year old husband had angioplasty and a stent done on an artery that was 95% blocked. He has another one that is 60% blocked. I have read on the internet that in 6 months about 40% of these arteries block up again. Is this true?
Today he experienced some pressure on the left side of his chest and tingling in his arms that went away after 2 hours. He didn’t have any pain. Is this normal?
We are from Florida and used to eat a diet high in fat. We lowered it to 40grams per day. He is trying to quit smoking. Can he wear a nicoderm patch?
He had angioplasty 2 weeks ago. We have an HMO insurance and the providing cardiologist can’t see him for 2 more weeks. Our regular doctor prescribed Vistaril to help him quit smoking, but the description says its an antihistamine. Is this safe? He didn’t take the Vistaril today.
He doesn’t have high blood pressure, a weight problem, or any other health problems. I’m sure the smoking and high fat diet caused this, so we really need some professional advise on how to help him to quit smoking so soon after angioplasty.
It is always best to check with your own doctor about your husband’s medical condition.
This being said, the rate of re-occlusion depends on the size of the vessel that was stented and the 40% figure you have found may be the occlusion rate before the use of stents, or with angioplasty alone. Stents in larger arteries tend to decrease re-occlusion rates by 50% or more.
It is also important is to take an antiplatelet drug-like Ticlid for the first two weeks post stenting with this usually followed by Aspirin. Vistaril is an antihistamine and sedative. Smoking is a very bad addiction, but remember the most important element of stopping is the will to quit. If you want to stop smoking you can, if you don’t want to stop you won’t, probably no matter what you do. The risk of nicotine patches is probably less than the risk of smoking, as all they do is give you a source of nicotine to feed the addiction. That is why you can not smoke with the patches.
Most people who want to stop smoking can and the nicotine patches can help.
It is not surprising that there is another 60% lesion, as the cholesterol builds up everywhere in the arterial system. The narrowings that you are aware of are just a warning that the disease is active. While angioplasty and stenting can relieve angina, where a patient will be in a few years depends mostly on cutting out cigarettes completely, lowering the fat content of the diet, exercising and the use of lipid-lowering drugs if the serum cholesterol is higher than desired.
Heart pain is usually not called pain but rather pressure, tightness or heaviness. It can radiate to an arm, the throat, the back, the teeth or sometimes to an old injury in the chest. If the pattern changes (more frequent, longer duration, or just plain new) it should be taken seriously and your doctor called or an emergency room visited if in doubt. Two hours is a long duration for discomfort and can indicate a re-occlusion of the artery.
Remember, the greatest risk with a heart attack is in the first hour (if not the first few minutes). This is a good time to be in an emergency room or an ambulance!
One year ago, during an attempted angioplasty of the left anterior descending artery, the circumflex artery was accidentally dissected. This led to coronary triple bypass as a result. The damage caused by the ensuing heart attack caused mild regurgitation of the mitral valve and a hypokinetic left ventricle.
I would like to know more about the implications of these two conditions. Can you help me?
To answer your questions about mitral insufficiency and hypokinetic left ventricle would require a lecture requiring a few hours. The short version is that Hypokinesia means partial damage to the left ventricle that can be reversible in the long run. Akinesia or dyskinesia are usually non reversible. This damage is likely to have occurred at the time of your heart attack or may have been present prior to the angioplasty attempt. Lack of blood flow to the heart muscle caused by a coronary artery stenosis leads to hypokinesia. In general the degree of hypokinesia will be important in determining the long term outcome.
Mitral regurgitation means leaking of the mitral valve which is the valve between the left atrium and the left ventricle. Damage to this valve can occur in many ways. This can be a chronic degenerative condition, an acute infectious process, it can be secondary to enlargement of the left ventricle or more likely in this situation to damage to the papillary muscle which attaches the mitral valve to the heart muscle. Again this condition could have been present before or occurred at the time of the failed angioplasty. And again the degree of mitral regurgitation is important in determining the long term outcome. The lesser the regurgitation the better the outcome.
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