Open-heart surgery generally means an operation in which the heart-lung machine is used to support the patient’s circulation while the surgeon opens the chest and makes changes to the heart or the arteries on the surface of the heart. This surgery is one of the most commonly performed operations in the United States, with a high overall survival rate. There are a variety of types of open-heart surgeries, depending on the condition being treated and the overall health of the patient.

In general, patients undergoing open-heart surgery can expect a hospital stay of at least three to four days after the surgery. They will not be allowed to smoke for two weeks before the procedure, or to eat or drink for eight hours beforehand. They will usually be admitted on the morning of the procedure. The procedure itself takes an average of about five hours. Afterward, the patient will be very carefully monitored, first in the cardiac intensive care unit and then on the general floor. Most open-heart surgeries will not need to be repeated.

The term open-heart surgery generally refers to an operation in which the heart-lung machine is used to support the patient’s circulation while the surgeon opens and makes changes to the heart. The definition, however, is somewhat fluid. The term may also be used to describe bypass surgery, which is used to treat coronary artery disease (CAD) – a chronic disease in which there is a “hardening” (atherosclerosis) of the arteries on the surface of the heart, resulting in an obstruction of the flow of blood to the heart muscle. During bypass surgery, the surgeon places a conduit vessel to the blocked coronary arteries, which lie on the surface of the heart, and the heart is not opened. Open-heart surgery has also been used to describe procedures that do not involve the use of the heart-lung machine (e.g., off pump bypass surgery).

According to the American Heart Association (AHA), approximately 666,000 open-heart surgeries were performed in 2003. Following is the breakdown of that statistic:

Patients should prepare in advance for a hospital stay of at least three to four days. The patient is usually admitted on, or a day before, the scheduled date for an open-heart surgery. In the hospital, the patient will undergo a battery of tests. Even if these tests were already performed days or weeks before surgery, they may be performed again just before surgery to be sure that the patient’s medical condition has not changed. They include:

• Chest x-ray. A radiation-based imaging test that offers the physician a picture of the general size, shape, and structure of the heart and lungs.
  
  
• Lung function test and studies to detect obstructions of the carotid arteries. 

Eight hours before surgery, all patients are placed on NPO (non per os; nothing by mouth) status. That means they are not permitted to eat, drink or take anything by mouth until after their surgery. Smokers will have been instructed to completely avoid smoking for at least two weeks before their surgery to prevent problems in blood flow, clotting or breathing. Certain medications may need to be reduced or stopped temporarily, so patients should discuss their medication schedules with their heart surgeon before surgery.

Immediately before surgery, the patient will be given specific pre–operative medications and be “prepped” for surgery. First, the chest area is shaved. Next, the surgical team creates a sterile environment by swabbing the patient’s chest with an antiseptic solution and covering the area with sterile surgical drapes. An intravenous (IV) line will also be started, usually in the forearm or back of the hand.

The patient is then given a sleep-inducing medication through the IV. The patient will continue to breathe a mixture of oxygen and anesthetic gas (general anesthesia) to make sure that he or she remains asleep throughout the entire surgery.

After the patient is asleep, a device called the Swan-Ganz catheter is often inserted into the jugular vein (in the neck) and threaded to the pulmonary artery (which goes from the heart to the lungs). The catheter is used to measure heart function and heart and lung pressure. It can also be used to give medication and measure the oxygen levels in the blood. A breathing tube (endotracheal tube) will also be inserted into the mouth and down the windpipe (trachea) to maintain an airway. A urinary catheter is also inserted and connected to a collection bag to measure the patient’s urine output.

An 11- to 12-inch incision is made in the chest and the breastbone is split in two (full median sternotomy). A retractor is then used to pull back the breastbone and ribs in order to open up the chest. The functions of the heart, including blood flow and oxygenation, are rerouted through a heart-lung machine, so that the heart can be safely stopped during the procedure by the injection of a cooled cardioplegia solution.

The cardiac portion of the procedure then begins, according to what the particular condition requires:

Some open-heart procedures are used to correct or relieve congenital heart defects. Annually, there are about 20,000 open-heart surgeries performed on children in the United States. Infants under one year of age comprise approximately 90 percent of pediatric open-heart surgeries, which include:

• Norwood procedure. A series of surgeries to treat hypoplastic left heart syndrome, in which the chambers, valves and related blood vessels on the left side of the heart are so malformed that they cannot efficiently pump blood to the rest of the body. Each open-heart surgery is done at a different age, ranging from infancy through the toddler years. The first two surgeries (Stages I and II) are used to temporarily relieve blood flow problems to and from the lungs. The third surgery (Stage III), known as the Fontan procedure, is used to further improve the circulation but cannot cure the underlying heart defects.

 

• Arterial switch operation. To treat transposition of the great arteries (TGA), in which the aorta and the pulmonary artery are in reversed locations, resulting in oxygen-rich blood from the lungs not being able to get to the brain and the rest of the body. During the procedure, the pulmonary artery is disconnected from the pulmonic valve, which arises from the left ventricle. The aorta is disconnected from the aortic valve, which arises from the right ventricle. The aorta is then connected to the pulmonic valve, so that it is exiting from the left ventricle, as it should. The pulmonic valve is connected to the aortic valve, so that it is exiting from the right ventricle, as it should.

  
• Rastelli procedure. To treat a number of cyanotic heart defects that restrict the normal flow of blood from the heart to the lungs. The Rastelli procedure is used when a hole in the heart is involved in the defect. The hole is patched to redirect blood flow. Some of these defects include: transposition of the great arteries (TGA) with ventricular septal defect (VSD), pulmonary stenosis, pulmonary atresia (complete closure of the pulmonic valve) with VSD and double outlet right ventricle (DORV) with pulmonary stenosis.

Once an open-heart procedure is completed, the incision is closed and the heart is restarted. When the surgical team is satisfied that the heart is beating strongly again, the heart-lung machine is disconnected. The chest incisions are then closed (sutured).

After surgery, the patient is moved to a hospital bed in the cardiac surgical intensive care unit. Heart rate and blood pressure monitoring devices continuously monitor the patient for 12 to 24 hours. Family will be able to visit periodically. Medications that regulate circulation and blood pressure may be administered through an I.V. (intravenously). A breathing tube (endotracheal tube) will remain in place until the physicians are confident that the patient is awake and ready to breathe comfortably on his or her own. The patient may be groggy and somewhat disoriented, and sites of incisions in the chest (and the leg, if this was a bypass operation) may be sore. Medicine to relieve pain will be given as needed.

Patients usually stay in the hospital for four days to a week or longer. During this time, more tests will be conducted to assess and monitor the patient’s condition. The heart surgeon and cardiologist will discuss further medical treatment, including the use of pain medications or possibly anticoagulants. He or she will also update any medications that the patient had already been taking.

After release from the hospital, patients may have experiences such as:

Many of these usually disappear over the course of four to six weeks. When patients are ready, physicians may place them in a physician-supervised strength building cardiac rehabilitation program.

The ideal result of an open-heart surgery is the correction of a congenital defect, repair/replacement of a defective valve or bypass of a blocked artery with no further surgery necessary. However, every patient is unique and some conditions require follow-up procedures. In the case of the coronary artery bypass graft, for instance, a second surgery is usually not needed unless the artery re-narrows (restenosis) or closes altogether, which happens in 5 to 20 percent of patients. Changes in the patient’s lifestyle can be an important factor in determining whether another operation is necessary.

Although modern open-heart surgery has become a fairly common procedure, with a high overall survival rate, it does carry a risk of complications. This risk tends to be higher in older people and/or those with other serious medical conditions prior to the surgery. About 5 to 10 percent of patients experience strokes or transient ischemic attacks either during or shortly after open-heart surgery. Other complications include bleeding and infection.

Conventional open-heart surgery, which has been around for almost 50 years, requires the use of the heart-lung machine to take over the heart’s functions during surgery so that the heart can be carefully stopped and worked on.

Conventional open-heart surgeries usually involve a full median sternotomy, in which the chest is opened, the heart stopped and blood re-routed through a heart-lung machine. However, there have been a number of advances in open-heart surgery, including procedures in which the heart is operated on without opening the chest, and/or the heart is allowed to continue beating (off pump coronary artery bypass [OPCAB]).

OPCAB surgeries in particular have become more popular. It is estimated that as many 20 percent of bypass surgeries performed in the United States in 2002 were OPCAB surgeries. These may be performed through a standard sternotomy incision, or through the use of smaller incisions. During an OPCAB, the heart is stabilized through the use of special devices and the heart-lung machine is not used. Although the use of heart-lung machines is routine, it has also been associated with a number of serious complications, such as a greater risk of heart attack or stroke.

Researchers have also developed surgeries that are performed through very small, “key hole” incisions in the chest. These are known as minimally invasive direct coronary artery bypass (MIDCAB for short) surgeries and have been performed on patients with comparatively mild forms of heart disease. Minimally invasive heart valve surgeries have also been performed on patients whose conditions may be too unstable for conventional open-heart surgery. MIDCAB procedures may be performed with or without the heart-lung machine.

Minimally invasive procedures offer a number of advantages over conventional open-heart surgery. They are less traumatic and require smaller incisions. However, not all patients are candidates for minimally invasive procedures. For instance, a MIDCAB is typically reserved for cases in which only one or two grafts are required, and treatment is often limited to blockages in the left anterior descending coronary artery (LAD).

Catheter-based procedures, especially balloon angioplasty with or without stent placement, are also decreasing the number of open-heart surgeries necessary. During a balloon angioplasty, the physician guides a thin plastic tube through the circulatory system and into the coronary arteries. When the catheter has reached the site of a blockage, the balloon is rapidly inflated, crushing the arterial plaque against the wall and opening up the vessel. In many cases, a stent is also implanted. A stent is a tiny metal mesh that is permanently left in the artery. Stents have been shown to reduce the incidence of restenosis, or reclosure of the artery, the reducing the need for further procedures. Catheter-based procedures can also be effective in treating heart-valve disease and certain congenital heart diseases, such as an atrial septal defect. Like minimally invasive procedures, catheter-based procedures offer a treatment option with less trauma and pain for the patient. However, these procedures also carry certain risks.

Preparing questions in advance can help patients to have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor the following questions related to open-heart surgery:

1. What type of open-heart surgery do you recommend for me?
   
   
2. Will my surgery be completed in a single procedure?
   
   
3. How likely is it that my procedure will be completed successfully? What could go wrong?
   
   
4. How long will it take me to recover from the type of surgery you are recommending?
   
   
5. Are there any alternatives to open-heart surgery available to me?
   
   
6. Who will my surgeon be? How much open-heart surgery experience do they have?
   
   
7. Will I need to regularly visit a cardiologist following my surgery? For how long?
   
   
8. Will I need to take any medications regularly after my open-heart surgery? For how long?
   
   
9. Are there any activities I will no longer be able to engage in after my surgery?
   
   
10. Can I undergo open-heart surgery if I am pregnant? Could open-heart surgery affect my ability to get pregnant?