Heart Bypass Surgery
Heart Bypass Surgery is an open-heart surgery that is used to treat blockages of the heart arteries. When there is a heart artery blockage, blood supply to areas of the heart are affected. A heart bypass is attached beyond the blockage restoring blood flow to that area. Heart bypasses are either arteries or veins taken from other parts of the body including the chest wall and the legs. This article is a picture guide to heart bypass surgery that takes you through many critical stages of the operation.
heart bypass surgery beating heart with bypass attached
Coronary artery bypass grafts; three grafts are depicted here, a left internal mammary artery (LIMA) to left anterior descending (LAD) and two saphenous vein grafts – one to the right coronary artery (RCA) system and one to the obtuse marginal (OM) system. The LIMA graft is surrounded by yellow fatty tissue in the forefront of the diagram, the RCA graft departs the left side of the aorta and wraps around the heart on the left side of the diagram, the OM graft departs the right side of the aorta and wraps around the heart on the right side of the diagram.
The Heart Bypass Vessel
The most well known bypass is called the LIMA to LAD. LIMA stands for left internal mammary artery and is an artery that runs from the left collarbone area down the chest wall. LAD stands for left anterior descending artery which is the artery commonly responsible for the ‘Widowmaker Blockage.” In a bypass it is carefully taken down from the chest wall and attached beyond a blockage acting as a bypass. The LIMA to LAD is very successful as a bypass and has good long-term results. In other types of bypasses, arteries can be taken from the forearm, or veins can be taken from the legs. Read this article on heart blockages and this article on the ‘Widowmaker” for more information. This article titled “how long does a bypass last” is useful and goes in to a little more depth about the different bypasses.
The Left Internal Mammary Artery (LIMA) is depicted here and is labelled #8.
Heart Bypass Surgery – A Picture Guide
Heart Bypass surgery Cutting superficial with electocautery
Cutting The Skin
The first operative step in a heart bypass surgery is cutting the chest wall to expose the breastbone. A scalpel is used initially. Then electrocautery is used to dissect through the superficial layers. In these images the superficial tissues are dissected through, then the deeper layers down to the breastbone.
Heart Bypass Cutting To Breastbone With Electrocautery
Sawing Open The Breastbone
Heart bypass surgery is an open-heart surgery and the heart needs to be exposed. In the case of bypass surgery this is done by sawing through the breastbone in a technique known as median sternotomy. A specially designed electric saw is used for this. A median sternotomy is demonstrated in the next image. Once the bone is cut, small bleeders are cauterized to stop the bleeding.
Heart Bypass Surgery Electric Saw Through Breastbone
Heart bypass surgery cauterizing bleeding breastbone vessels
Freeing Up the LIMA
As described above, the best bypass to use when possible is known as the LIMA. This runs on the left inner chest wall. In this next image the breastbone on the left is retracted and then the LIMA is freed up from the chest wall so it can be used as a bypass.
Heart Bypass Surgery Retracting the Breastbone
heart bypass surgery cauterizing bleeders under the chest wall
Harvesting The Leg Vein
In the old days of heart bypass surgery the leg was literally cut open to expose then harvest the leg veins to be used as bypasses. A more modern technique is known as endoscopic harvest where a small endoscope is inserted in to the leg and a keyhole technique is used to take out the vein to be used as a bypass. This leaves us with a much smaller leg wound and improved healing with less complication.
heat bypass surgery keyhole leg vein harvest
hyeart bypass surgery vein after endoscopic harvest
Heart Bypass Surgery Keyhole leg vein harvest
heart bypass surgery keyhole leg vein harvest 2
Putting the Patient On Cardiopulmonary Bypass
The patient undergoing heart bypass surgery is placed on a heart lung bypass machine to take over the work of the heart during the operation. This allows the heart to be stopped. Some people advocate doing heart bypass surgery on a beating heart, most do not, it is an ongoing debate with no clear winner.
Preparing The Heart Bypasses
The bypasses are cut appropriately. The small branches on the side are clipped so blood isn’t lost when they are attached. The veins are expanded with fluid to ensure they are competent for use.
heart bypass surgery preparing the vein to use as a bypass
Attaching The Bypasses
The arteries to be bypassed are carefully exposed. The bypass grafts are then carefully attached. Good technique here is critical to ensure good results.
heart bypass surgery carefully exposing the blocked artery
heart bypass surgery attaching the bypass graft
Other Operations
In many patients other operations will be needed at the same time. Patients with mitral regurgitation (a leaky mitral valve) or mitral stenosis (a tight mitral valve) may need mitral valve repair or mitral valve replacement at the same time. Patients with aortic stenosis or aortic regurgitation may need aortic valve replacement at the same time also.
Restarting The Heart
Once the heart bypasses are attached the heart can be restarted so it can start beating again in its normal fashion.
heart bypass surgery beating heart with bypass attached
Closing The Chest
The breastbone is closed using a technique known as sternal wiring to hold it together until it heals over time. After that the superficial tissues and the skin can be sutured together. Drains are left in the heart sac and the lungs to allow drainage of blood over the next 24-48 hours.
heart bypass surgery wiring the breastbone back together
heart bypass surgery closing skin and placing drains
To The ICU
After heart bypass surgery the patient will be transported to the cardiac intensive care unit. The breathing tube is typically taken out the same day. Patients are typically in the hospital 3-5 days after heart bypass surgery.
This article was extremely helpful in understanding just what will happen during surgery. It is very informative.
I had triple by-pass surgery 12 years ago and now the arteries are blocked again even after losing 80 pounds, taking medications faithfully, etc. Is it possible to have more surgery?
Redo bypass surgery is certainly possible if required but depends on many factors including the health of the patient and the condition of the heart. These situations require a good work up. This may include viability testing to see if the heart tissue is viable and would benefit from reestablishing blood supply. There have been significant advances in stent technology also and there may be options such as CTO procedures.
Given the large amount of people we have been able to help here, we are starting a twitter to help keep heart patients up to date with advances and relevant information. Mine can be followed at @MustafaAhmedMD
What’s better for a 100% blocked LAD? LIMA or stent?
It differs in every case and i would need to see the films and know the story to comment. In most cases, if a good sized LAD and totally occluded, LIMA is a good option given its longevity, particularly if the disease is considered conplex.
Given the large amount of people we have been able to help here, we are starting a twitter to help keep heart patients up to date with advances and relevant information. Mine can be followed at @MustafaAhmedMD