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13. Bypass surgery

I have had medication and lots of tests for angina. I am now being offered bypass surgery. Why do I need this?

Operations for coronary artery disease are usually designed to improve the blood supply to the heart. A decision by the consultant as to whether to advise an operation for you is based on your case history and on several special tests, including an electrocardiogram, an exercise test and an angiogram. This last test is the most crucial one for bypass operations as it demonstrates the exact position and extent of the narrowings. An operation may be advised because of the severity of the symptoms or the extent of the disease or both.

The operation may be performed to make you feel better, to prevent a heart attack or to correct life-shortening disease, thus giving you a longer and more active life.

Can you tell me what the bypass operation is all about?

The most common operation for angina is a coronary artery bypass. The full name is Coronary Artery Bypass Graft or CABG – often referred to as ‘cabbage’.A portion of vein is carefully removed from the leg and attached to the affected coronary artery beyond the narrowing. The other end of the vein is attached to the aorta, the main artery leading from the heart. In other words, the narrowing or obstruction is bypassed, just as a road bypass can avoid bottlenecks in towns.

Several of these vein grafts may be placed, often one to each of the three major coronary artery branches. Frequently the graft is made with the left and right mammary artery from inside the chest. The radial artery is more frequently used now and taken from your lower arm between the wrist and elbow. Artery bypasses are believed to be stronger and longer lasting than vein bypasses. In each case your body can put up with the loss of the vein or artery used for the bypass.

In order to do these operations, the surgeon requires your heart to stop beating; so the heart and lungs are rested while the body is kept going by a heart-lung bypass machine. The operation is carried out through an incision down the front of the chest.

I read that some people can have a bypass without the need for a heart-lung machine – is this keyhole surgery?

Not really keyhole, but in selected cases the bypass can be done with the heart still beating. This is known as ‘off-pump’. In appropriate cases the results are good and there may be fewer complications. The surgeon will decide who is suitable, based on the angiogram and medical history.

I am rather confused about the differences between the cardiologist and the surgeon – aren’t they the same?

No. The cardiologist is a medical doctor and heart specialist who makes the diagnosis, investigates and treats you, and decides what is best to be done. The surgeon is a medical ‘plumber’ who puts in the bypasses and heart valves. When the job is done, the surgeon usually hands you back to the cardiologist to keep an eye on you. The cardiologist and surgeon work closely as a team to advise on and time the best treatment for you.

My doctor says that my heart has done its own bypass – what does he mean?

The coronary arteries link up through very small branches – they don’t come to a full stop. This means that the left coronary artery can supply the right via the links, and vice versa. If these branches enlarge, they may fill a blocked artery backwards.

This means, for example, that a blocked right coronary artery may get its blood supply from the left system. The enlarging arteries are known as collaterals. Collaterals develop over time and can be encouraged by regular exercise. If you ‘develop collaterals’, so that a blocked artery gets its blood supply from another artery, it is then as if you have done your own bypass because, in effect, the blockage has been bypassed by your own arteries.

What do you use for a bypass operation if there are no suitable veins?

You have two arteries in the chest that can be used, two spare ones in the arms and also in the abdomen. The surgeon will find a way around the problem.

My doctor has recommended a bypass operation, but after all I’ve read about it, I don’t think I want to have it done. Am I being used as a guinea pig?

The risks of severe coronary artery disease are higher if you do nothing. It is always important to discuss your own risks so that you and your family know where you stand. Risks will vary with age, how strong your heart muscle is and the extent of the coronary disease. On average, 98 patients in 100 pull through and two therefore do not.

So you have a 98% rate of success but, if you are one of the other 2%, you have a 100% chance of dying. The odds are heavily on your side but it is important to understand what the statistics mean. If, for example, I told you that, because the operation is difficult, you had a 98% chance of living, you would feel differently to hearing that you had a one in 50 chance of dying, even though the figures mean exactly the same!

How long will a bypass graft last?

It used to be said that bypass surgery lasted 10 years, but these figures are out of date. The mammary artery bypass has a better than 90% chance of working for longer than 15 years after surgery. The veins can still harden and narrow but, with the use of aspirin and

cholesterol-lowering medication, the length of time these bypasses last is improving all the time. The success depends on dealing with those factors that you have some control over, in particular high cholesterol levels, smoking and high blood pressure.

What happens before the bypass operation?

The surgeon who is going to perform the operation will examine you and explain what is planned. It is a great help for you to have your teeth checked by your own dentist well beforehand so that lastminute treatment can be avoided.

This is to make sure there is no hidden infection that might affect the operation. Blood samples will be taken for tests; an electrocardiogram and a chest X-ray will also be taken. You will be visited by the physiotherapist and intensive care unit nursing staff to explain details of treat ment to you. Before the operation, the anaesthetist will check on your lungs and ask about any allergies.

The anaesthetist is a very important member of the team – your breathing will be controlled whilst the operation is being carried out.

Your chest and legs will be carefully shaved and you will be given a special antiseptic soap to clean the skin in several baths or showers. You will not have any food or drink for 4 hours before the anaesthetic is due. About 1 hour before the operation an injection will be given which will make you drowsy. The next thing you will know is waking up in the intensive care unit with the operation completed. The operation will take about 2–4 hours.

Why is the intensive care unit different to a normal ward?

The intensive care unit (ICU) is a halfway house between the operating theatre and the ward. You can be carefully observed there until you are again fit to be left to your own devices. Immediately after the operation you will still be fully anaesthetised and on a breathing machine. On awakening several hours later, you will have a tube in your mouth attached to the breathing machine, so that for a little while you will not be able to speak properly.

This can be frightening at first and frustrating. However, as soon as you are fully awake, the tube is removed. As you are likely to be very thirsty at this time, you may take sips of water. The ICU is busy and noisy with lots of sophisticated machines.

They are all there to help you and make sure the operation is a success. You may find it hard to rest. As soon as the nursing staff considers that it is safe to do so, you will be transferred to the main ward. You may feel that you have lost a day or are ‘jet-lagged’ and it is easy to be confused, but matters soon right themselves and you will soon feel yourself again.

One of the first visitors to the ICU is the physiotherapist. During the operation there is a tendency for your bronchial tubes to collect sputum and become blocked, causing small areas of collapse in the lungs. These then have to be fully expanded again by deep breathing and coughing with the encouragement and assistance of the physiotherapist.

Naturally, after such an operation, your chest will be sore and you may be somewhat anxious about exerting yourself. However, with proper pain-killing injections and tablets, and knowing that there is no danger of ‘bursting’ stitches, you will soon overcome this fear. Giving up smoking as long as possible before the operation will greatly help in this respect.

What happens on the normal ward when I get transferred?

As far as operations go, bypass surgery is not one of the most painful, but many people often complain of feeling a bit low in spirits for a few days afterwards.

This is only temporary and may be accompanied by other symptoms such as fatigue, poor concentration, slight blurring of vision, loss of taste, a disturbance of sleep pattern with drowsiness during the day, and restlessness and sweating at night. All these symptoms very rapidly pass off and are no cause for alarm. If it hurts to cough, clutch a small pillow to your chest (or better still a teddy bear – a present for your recovery!).

If you become constipated, mention it to the Ward Sister who will provide a mild laxative.

After one or two days, you will be encouraged to get out of bed and walk about. People vary greatly in their speed of recovery and getting up and about. There are no set rules – so if someone else appears to be doing better than you, it does not mean that anything is wrong. There is no competition involved! The nurses and physiotherapists will encourage you to get on your feet as fast as you can manage it without becoming exhausted.

You will usually be given support stockings for your legs, to prevent swelling and to keep your circulation moving. It is important that, when you are resting, you keep your legs raised on a stool or in bed, to avoid swelling during the first few days.

After about 6 to 7 days, any stitches will be removed from your chest and leg. You can have a bath if you want one. Leg wounds take longer than most to heal, and there may be a discharge of clear fluid, especially if your leg is not kept raised. This is not serious but should be pointed out to your doctor. It may feel a little numb just above the ankle on the inside of your leg.

Is it normal to get chest pains after the operation?

Muscular pains are common and can affect the chest, neck and back. They usually wear off over 2–3 weeks but can remind you of the operation for 2–3 months. Occasionally, bone and joint pain is a significant problem and anti-inflammatory tablets are prescribed.

Most pains settle with simple painkillers, e.g. paracetamol or the stronger co-dydramol.

Can I lie on my side after a bypass operation?

You can lie in any position that you find comfortable.

Can the wound from a bypass operation fall apart?

No – your breastbone is wired together and you cannot undo the stitches or damage the operation. Very rarely the breastbone does not heal quickly and a click will be heard.

I am told that bypass surgery will make a large scar. Can’t it be done by keyhole surgery?

Keyhole surgery is a media phrase – it does not happen in real life. In a few carefully selected cases, a bypass operation can be done without the need to open the breastbone or stop the heart. A cut is made to the side of the breastbone through three or four ribs and, whilst the heart is still beating, the surgeon constructs the bypass.

Recovery is quicker than after a full bypass operation. It is a new procedure that is very appealing to the public, but applicable only to a small number of people, and it needs more testing to prove its effectiveness. If you are offered this option, ask about your particular surgeon’s results and whether you will be entered in a research study to judge the success.

Some surgeons are now opening only the lower end of the breastbone, which means that women can wear lower-cut garments, if they wish, without the scar showing.

I had a bypass some weeks ago. My scar is still tender. Why is this?

At the end of the operation, wires are used to pull the breastbone together and hold it firm for healing – these are not usually removed. It sounds as though you are one of the small number of people who feel the ends of these wire stitches. This may settle down or only be an occasional problem; however, occasionally they can give trouble.

The problem can usually be pinpointed by pressing with a finger. If this problem occurs, the wires can be removed under anaesthesia by your surgeon, because once the breastbone has healed the wires are no longer necessary.

My chest scar is pink and overgrown, following my bypass operation. Can it be improved?

Occasionally, an operation scar may become pink and enlarges like a ridge. This is known as a keloid. It can be tender, itchy and unsightly. If it is a problem, steroid creams can be tried in order to relieve the discomfort. If it is intolerable, the scar can be cut out and then deep X-ray treatment given to stop the skin cells enlarging again.

I am due out of hospital in a few days after a successful bypass operation. What problems might I have?

Most people go straight home providing there is someone there to help. If you live alone, it is best to spend the first 2 weeks with relatives or friends but, if this is not possible, your doctor should arrange, preferably before the operation, for your convalescence in a convalescent home. You will be given a supply of painkillers, a letter for your family doctor and advice on aspirin, diet and cholesterol medication. If you suffered from high blood pressure beforehand, this usually returns after the operation and will need careful checking.

Almost certainly your blood pressure medications will need restarting.  When you return home, you may feel tired for a week or two. Although you are not exerting yourself, your body is doing a lot of repair work during this time.

How will I know that my bypass operation has been successful?

Your angina will be much less or non-existent. You will be less short of breath and have much more energy. You may say to yourself, ‘I didn’t realise how tired I had been’, as you discover a new lease of life. A bypass should be a new start for you and your heart.

What exercise can I do on leaving hospital after my bypass operation?

Regarding exercise, you can do what you like within the bounds of commonsense! Unless carried to extremes, exercise will not hurt you. Any excess exercise will simply make you feel exhausted, and you can use this as a sign by which to pace yourself as you regain

your fitness. In fact, regular exercise is an important factor in rehabilitation. There is no reason to avoid normal sexual activities. The main problem may be pain from the muscles in the chest. If there are any problems do not avoid the subject, ask for help from your own doctor. Hairs on men’s chests are prickly when they regrow and their partners may find this uncomfortable. A small soft pillow placed over the chest between partners can help.

I have a small garden at home. I’m due for a bypass operation next month. When will I be able to start gardening again?

Gardening is a good, rewarding form of exercise. Pace yourself doing the light work at first (weeding, dead-heading). Kneel down rather than bend over, to avoid muscular chest pain. Dig light soil but avoid any heavy clay soil until you are fully recovered. Cutting the grass should be possible after 3–4 weeks if the mower is light (such as a hover type).

Avoid heavy work (lifting bags of fertiliser) or pushing a heavy roller mower until 6–8 weeks, when you should be back to normal.

I have been told that I should go on a cardiac rehabilitation programme. What does this involve and do I really need it, now that I feel so much better?

These programmes are strongly recommended as they give you structured advice on exercise and help you get out and about to meet others; these gatherings are a great boost to your confidence. In fact, you should positively demand to go on one! If one is not offered to you, make enquiries from the hospital where you had the operation or, if these long distances away, ask your doctor or local cardiac unit. Rehabilitation programmes have been proved to help you get back to a normal life quicker, and there is now evidence that, if you follow all the advice, you will prevent problems in the future. You discover that you are not alone and you will find help is plentiful and advice freely given.

Are rehabilitation programmes just about exercise?

No – they offer lots of general advice. They assess whether you are anxious or depressed, advise on stress and how to relax, and you can raise any concerns you might have, for example, about resuming sexual activity, diet or which medication you need to take.

Now that I am back home after my bypass operation, how soon can I start driving again?

You should be able to drive your car 4 weeks after the operation. Check first with your doctor. The Drive Licence Department in many countries does not need to be notified but your car insurance company does. If you drive a heavy goods vehicle, you will have to pass an exercise test 6 weeks after the operation.

I would like to have a holiday now that I have had my bypass – would this be a good idea?

Yes indeed. A period of relaxation in a warm climate helps recovery. Airlines prefer you to wait 6 weeks before travelling and this is a good time in your recovery as it helps you get back to full strength. If an emergency arises and you need to travel by plane before the 6 weeks, there is usually no problem, but you may need a doctor’s letter saying that it is all right to travel.

Some travel insurance companies also require a letter. At the airport, the wires in your chest do not usually set off the alarms, but as the equipment’s sensitivity varies from airport to airport, you may rarely set the alarm off. Stents do not usually sound the alarms either, but pacemakers do. After an angioplasty or stent placement, you may travel sooner – even within a week, although the doctor usually advises waiting 7–14 days.

How soon can I go back to work after a bypass operation?

If you were able to work before the operation, you should be back at work 2–3 months later. If your job involved hard physical labour or long working hours, ideally you should try to find a less strenuous job. However, hard physical work is safe if you become strong and fit again – ask the rehabilitation team to advise on strength-building exercises.

If you are over 60 years of age, you should think about early retirement if this is financially possible.

I feel very tired with angina and I am looking forward to having my bypass operation. Will I really feel better after surgery?

You should feel fitter and stronger with much less or no angina. Many people feel much less fatigued.I didn’t really see the purpose of bypass surgery, but am prepared to undergo it if I can guarantee avoiding this terrible pain. I couldn’t bear the thought of the operation not working.

How can I stop my angina returning later?

Follow the guidelines on weight, exercise and cholesterol.

• Do not smoke.

• Make sure your blood pressure is normal and your cholesterol low. Your target LDL cholesterol should be below below 2.0 if possible. Once you have achieved this, keep it down. The target is lower for those who have undergone bypass surgery (1.7–1.8) in order to protect the veins that have been used from narrowing and hardening.

• Take charge of yourself and make sure you have your life under control as much as possible.

• Do not sit back and let others look after you all the time.

How long will I be in hospital following bypass surgery?

A total of 7 to 8 days on average. Older people and more complex cases may be kept in a little longer.



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