Heart Surgery Overview
Thousands of heart surgeries are performed every day in the United States.
Thousands of heart surgeries are performed every day in the United States. Even though there is a shortage of donor organs, more than 3,400 people have heart transplants each year.
Two major advances in medicine made heart surgery possible:
The heart-lung machine, which takes over the work of the heart.
Body cooling techniques, which allow more time for surgery without causing brain damage.
What is a heart-lung machine?
The heart-lung machine is also called a cardiopulmonary bypass machine. It takes over for the heart by replacing the heart’s pumping action and by adding oxygen to the blood. This means that the heart will be still for the operation, which is necessary when the heart has to be opened (open heart surgery).
When you are connected to the heart-lung machine, it does the same job that your heart and lungs would do. The heart-lung machine carries blood from the upper-right chamber of the heart (the right atrium) to a special reservoir called an oxygenator. Inside the oxygenator, oxygen bubbles up through the blood and enters the red blood cells. This causes the blood to turn from dark (oxygen-poor) to bright red (oxygen-rich). Then, a filter removes the air bubbles from the oxygen-rich blood, and the blood travels through a plastic tube to the body’s main blood conduit (the aorta). From the aorta, the blood moves throughout the rest of the body.
The heart-lung machine can take over the work of the heart and lungs for hours. Trained technicians called perfusion technologists (blood flow specialists, also called the “pump team”) operate the heart-lung machine.
What are cooling techniques?
Cooling techniques let surgeons stop the heart for long periods without damaging the heart tissue. Cool temperatures avoid damage to the heart tissue by reducing the heart’s need for oxygen.
The heart may be cooled in 2 ways:
Blood is cooled as it passes through the heart-lung machine. In turn, this cooled blood lowers body temperature when it reaches all of the body parts.
Cold salt-water (saline) is poured over the heart.
After cooling, the heart slows and stops. Injecting a special potassium solution into the heart can speed up this process and stop the heart completely. The heart is then safe from tissue injury for 2 to 4 hours.
Who is in the operating room during surgery?
During heart surgery, a highly trained group works as a team.
The cardiovascular surgeon heads up the surgery team and performs the key parts of the surgery.
The assisting surgeons follow the direction of the cardiovascular surgeon.
The cardiovascular anesthesiologist gives you the medicines that make you sleep during the surgery (called anesthesia) and monitors the ventilator, which breathes for you during surgery.
The perfusion technologists run the heart-lung machine.
The cardiovascular nurses are specially trained to assist in heart surgery.
What kinds of heart and blood vessel surgeries are there?
Coronary Artery Bypass
This is the most common kind of heart surgery, also called coronary artery bypass graft surgery (CABG), coronary artery bypass (CAB), coronary bypass, or bypass surgery.
The surgery involves using a healthy section of blood vessel from another part of the body to bypass a part of a diseased or blocked coronary artery. This creates a new route for blood to flow, so that the heart muscle will get the oxygen-rich blood it needs to work properly.
During bypass surgery, the breastbone (sternum) is divided, the heart is stopped, and blood is sent through a heart-lung machine. Unlike other kinds of heart surgery, the chambers of the heart are not opened during bypass surgery.
The terms single bypass, double bypass, triple bypass, or quadruple bypass refer to the number of arteries that are bypassed.
Valve repair or replacement
Blood is pumped through your heart in only one direction. Heart valves play key roles in this one-way blood flow, opening and closing with each heartbeat. Pressure changes behind and in front of the valves allow them to open their flap-like “doors” (called cusps or leaflets) at just the right time, then close them tightly to prevent a backflow of blood.
Two of the most common kinds of valve problems that require surgery are
Stenosis, which means the leaflets do not open wide enough and only a small amount of blood can flow through the valve. Stenosis (narrowing) occurs when the leaflets thicken, stiffen, or fuse together. Surgery is needed to either open the valve that is there or replace it with a new one.
Regurgitation, which is also called insufficiency or incompetence, means that the valve does not close properly and blood leaks backward instead of moving in the proper forward direction.
Surgery is needed to either tighten or replace the valve.
Surgical repair of a valve involves the surgeon rebuilding the valve so that it will work properly. Valve replacement means that the valve is replaced with a biological valve (made of animal or human tissue) or a mechanical valve (made from materials such as plastic, carbon, or metal).
Arrhythmia Surgery
Any irregularity in your heart’s natural rhythm is called an arrhythmia. Arrhythmias are usually treated first with medicines. Other treatments may include
Electrical cardioversion, where the cardiologist or surgeon uses paddles to “shock” the heart back into a normal rhythm.
Catheter ablation, where the cardiologist uses a special tool to destroy (ablate) the cells that are causing the arrhythmia. This is done in the cardiac catheterization laboratory (the cath lab).
Pacing and rhythm-control devices, including pacemakers and implantable cardioverter defibrillators (ICDs). Patients can have these devices implanted while in the operating room or the cath lab.
When these treatments do not work, surgery may be needed. One type of surgery is called Maze surgery. In Maze surgery, surgeons create a “maze” of new electrical pathways to let electrical impulses travel easily through the heart. Maze surgery is used most often to treat a type of arrhythmia called atrial fibrillation. Atrial fibrillation is the most common type of arrhythmia.
Aneurysm Repair
An aneurysm is a balloon-like bulge in a blood vessel or in the wall of the heart. An aneurysm occurs when the wall of a blood vessel or the heart becomes weakened. Pressure from the blood forces it to bulge outward, forming what you might think of as a blister. An aneurysm can often be repaired before it bursts.
Surgery involves replacing the weakened section of blood vessel or heart with a patch or artificial tube (called a graft).
Aneurysms in the wall of the heart occur most often in the lower-left chamber (called the left ventricle). These aneurysms are called left ventricular aneurysms, and they may develop after a heart attack. (A heart attack can weaken the wall of the left ventricle.) If a left ventricular aneurysm leads to an irregular heartbeat or to heart failure, the surgeon may perform open heart surgery to remove the damaged part of the wall.
Transmyocardial Laser Revascularization (TMLR)
Angina is the pain you feel when a diseased vessel in your heart (called a coronary artery) can no longer deliver enough blood to a part of the heart to meet its need for oxygen. The heart’s lack of oxygen-rich blood is called ischemia. Angina usually occurs when your heart has an extra need for oxygen-rich blood, such as during exercise. Angina is nearly always caused by coronary artery disease (CAD).
Transmyocardial laser revascularization (TMLR) is a procedure that uses lasers to make channels in the heart muscle, in an attempt to allow blood to flow from a heart chamber directly into the heart muscle. If the blood flow is increased, more oxygen can reach the heart. This procedure is only done as a last resort. For example, TMLR may be done in patients who have had many coronary artery bypass operations and cannot have another bypass operation.
Carotid Endarterectomy
Carotid artery disease affects the vessels leading to the head and brain. Like the heart, the brain’s cells need a constant supply of oxygen-rich blood. This blood supply is delivered to the brain by the 2 large carotid arteries in the front of your neck and by 2 smaller vertebral arteries at the back of your neck. The right and left vertebral arteries come together at the base of the brain to form what is called the basilar artery. A stroke most often occurs when fatty plaque blocks the carotid arteries and the brain does not get enough oxygen.
Carotid endarterectomy is the most common surgical treatment for carotid artery disease. Surgeons make an incision at the location of the blockage in the neck and a tube is inserted above and below the blockage to reroute blood flow. Surgeons can then remove the fatty plaque.
A carotid endarterectomy can also be done by a technique that does not require blood flow to be rerouted. In this procedure, the surgeon stops the blood flow just long enough to peel the blockage away from the artery.
Heart Transplantation
The first heart transplants were performed in the late 1960s. But it was not until the use of anti-rejection medicines in the 1980s that the procedure became an accepted operation. Today, heart transplantation gives hope to a select group of patients who would otherwise die of heart failure.
The need for a heart transplant can be traced to one of many heart problems, each of which causes damage to the heart muscle. The two most common heart problems are idiopathic cardiomyopathy (disease of the heart muscle without a known cause) and coronary artery disease (the buildup of plaque in the arteries of the heart).
As the heart problem gets worse, the heart grows weaker and is less able to pump oxygen-rich blood to the rest of the body.
Because the heart must work harder to pump blood through the body, it tries to make up for this extra work by becoming enlarged (hypertrophied). In time, the heart works so hard to pump blood that it may simply wear out, overcome by disease and unable to meet even the smallest pumping demands.
Medicines, mechanical devices to assist the heart, and other therapies (including stem cell therapy) can sometimes help and even improve a patient’s condition. But when those treatments fail, transplantation becomes the only option.
And Also:
Cardiac Procedures and Surgeries
If you've had a heart attack, you may have already had certain procedures to help you survive your heart attack and diagnose your condition. For example, many heart attack patients have undergone thrombolysis, a procedure that involves injecting a clot-dissolving agent to restore blood flow in a coronary artery.
This procedure is administered within a few (usually three) hours of a heart attack. If this treatment isn't done immediately after a heart attack, many patients will need to undergo coronary angioplasty or coronary artery bypass graft surgery (CABG) later to improve blood supply to the heart muscle.
Cardiac Procedures and Surgeries
Angioplasty
Also known as Percutaneous Coronary Interventions [PCI], Balloon Angioplasty and Coronary Artery Balloon Dilation. View an animation of angioplasty.
What the Procedure Does
Special tubing with an attached deflated balloon is threaded up to the coronary arteries. The balloon is inflated to widen blocked areas where blood flow to the heart muscle has been reduced or cutoff. Often combined with implantation of a stent to help prop the artery open and decrease the chance of another blockage. Considered less invasive because the body is not cut open. Lasts from 30 minutes to several hours. May require an overnight hospital stay.
Reason for the Procedure
Greatly increases blood flow through the blocked artery.
Decreases chest pain (angina).
Increases ability for physical activity that has been limited by angina or ischemia.
Can also be used to open neck and brain arteries to help prevent stroke.
Angioplasty, Laser
What the Procedure Does
Similar to angioplasty except that the catheter has a laser tip that opens the blocked artery. Pulsating beams of light vaporize the plaque buildup.
Reason for the Procedure
Increases blood flow through blocked arteries.
Artificial Heart Valve Surgery
(Also known as Heart Valve Replacement Surgery)
What the Procedure Does
Replaces an abnormal or diseased heart valve with a healthy one.
Reason for the Procedure
Restores function of the heart valves.
Atherectomy
What the Procedure Does
Similar to angioplasty except that the catheter has a rotating shaver on its tip to cut away plaque from the artery.
Reason for the Procedure
Increases blood flow through the blocked artery by removing plaque buildup.
May also be used in carotid arteries (major arteries of the neck leading to the brain) to remove plaque and reduce risk for stroke.
Bypass Surgery
(Also known as CABG, pronounced "cabbage," Coronary Artery Bypass Graft done via Open-Heart Surgery)
What the Procedure Does
Treats blocked heart arteries by taking arteries or veins from other parts of your body — called grafts — and using them to reroute the blood around the clogged artery to supply blood flow to your heart muscle. View an animation of blood flow(link opens in new window). A patient may undergo one, two, three or more bypass grafts, depending on how many coronary arteries are narrowed. Requires several days in the hospital.
Reason for the Procedure
One of the most common and effective procedures to manage blockage of blood to the heart muscle.
Improves the supply of blood and oxygen to the heart.
Relieves chest pain (angina).
Reduces risk of heart attack.
Improves ability for physical activity that has been limited by angina or ischemia.
Cardiomyoplasty
What the Procedure Does
An experimental procedure in which skeletal muscles are taken from a patient's back or abdomen. Then they're wrapped around an ailing heart. This added muscle, aided by ongoing stimulation from a device similar to a pacemaker, may boost the heart's pumping motion.
Reason for the Procedure
Increases the pumping motion of the heart.
Heart Transplant
What the Procedure Does
Removes a diseased heart and replaces it with a healthy human heart when a heart is irreversibly damaged. Uses hearts from organ donation.
Reason for the Procedure
Recognized as a proven procedure to restore heart health in appropriately selected patients.
Minimally Invasive Heart Surgery
(Also known as Limited Access Coronary Artery Surgery and includes Port-Access Coronary Artery Bypass (PACAB or PortCAB) and Minimally Invasive Coronary Artery Bypass Graft (MIDCAB or minimally invasive CABG)
What the Procedure Does
An alternative to standard bypass surgery (CABG). Small incisions ("ports") are made in the chest. Chest arteries or veins from your leg are attached to the heart to "bypass" the clogged coronary artery or arteries. The instruments are passed through the ports to perform the bypasses. The surgeon views these operations on video monitors rather than directly. In PACAB, the heart is stopped and blood is pumped through an oxygenator or "heart-lung" machine. MIDCAB is used to avoid the heart-lung machine. It's done while the heart is still beating. Requires several days in the hospital.
Reason for the Procedure
Manages blockage of blood flow to the heart and improves the supply of blood and oxygen to the heart.
Relieves chest pain (angina).
Reduces risk of heart attack.
Improves ability for physical activity.
Radiofrequency Ablation
(Also known as Catheter Ablation)
What the Procedure Does
A catheter with an electrode at its tip is guided through the veins to the heart muscle with real-time, moving X-rays (fluoroscopy) displayed on a video screen. The catheter is placed at the exact site inside the heart where cells give off the electrical signals that stimulate the abnormal heart rhythm. Then a mild, painless radiofrequency energy (similar to microwave heat) is transmitted to the pathway. This destroys carefully selected heart muscle cells in a very small area (about 1/5 of an inch).
Reason for the Procedure
Preferred treatment for many types of rapid heartbeats (arrhythmias) especially supraventricular tachyarrhythmias.
Stent Placement
What the Procedure Does
A stent is a wire mesh tube used to prop open an artery during angioplasty. The stent stays in the artery permanently. View an animation of a stent(link opens in new window).
Coronary narrowings can form again within stents and are referred to as “restenosis.”
Reason for the Procedure
Holds the artery open.
Improves blood flow to the heart muscle.
Relieves chest pain (angina).
Transmyocardial Revascularization (TMR)
What the Procedure Does
An incision is made on the left breast to expose the heart. Then, a laser is used to drill a series of holes from the outside of the heart into the heart's pumping chamber. In some patients TMR is combined with bypass surgery. In those cases an incision through the breastbone is used for the bypass. Usually requires a hospital stay.
Reason for the Procedure
Used to relieve severe chest pain (angina) in very ill patients who aren't candidates for bypass surgery or angioplasty.