Open Heart Surgery: Overview

Open heart surgery is an umbrella term for various procedures that involve opening up a person's ribcage through a large chest incision in order to expose their heart. This is a major operation that may be performed for a number of reasons including bypassing a blocked heart artery, repairing a diseased heart valve, or transplanting a healthy heart.

While the surgery offers many benefits and is often life-changing, recovery is usually gradual and challenging. After surgery, patients must be firmly committed to their follow-up care and heart-healthy lifestyle habits.

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What Is Open Heart Surgery?

Open heart surgery is an inpatient operation performed by a cardiothoracic surgeon or heart transplant surgeon in a hospital under general anesthesia. This type of surgery may be scheduled or performed emergently, depending on the patient's medical circumstances.

During open heart surgery, the surgeon makes a large incision in the middle of the patient's chest. The breastbone (which is connected to the ribcage) is then cut in half lengthwise and spread apart in order to expose the heart within the chest cavity.

Once the heart is exposed, the patient is connected to a heart-lung bypass machine. This machine takes over the heart's function, pumping oxygen-rich blood throughout the body. As a result, the surgeon is able to operate on a "still" heart (i.e., one that is not beating and has no blood flowing through it).

Open heart surgery may be performed for many different reasons. Most commonly, it is used to bypass a diseased heart (coronary) artery—what's called a coronary artery bypass graft (CABG). 

Various Surgical Techniques

Even though open heart surgery is an invasive technique, it's still widely used as it allows the surgeon to directly visualize the heart and its surrounding blood vessel supply.

That said, over the years, various minimally invasive approaches have emerged. These alter what most expect of open heart surgery in some key ways and may or may not be viable options, depending on the case.

For example, with the minimally invasive direct coronary artery bypass (MIDCABG) approach, the surgeon makes several small incisions on the left side of the chest in order to reach and operate on a patient's coronary arteries.

With this approach, most patients are not placed on a heart-lung machine. This means that the flow of blood through the body is maintained by the heart during the procedure; this is called "off-pump" surgery.

There are also minimally invasive valve repair or replacement techniques. With minimally invasive mitral valve surgery, for instance, a small incision is made on the right side of the chest. A specialized instrument is then inserted through the small opening and used to repair the valve.

Contraindications

Contraindications depend on the type of open heart surgery being performed.

With a CABG, for instance, relative contraindications include:

• Low risk of myocardial infarction (heart attack) or death with no symptoms
• Advanced age (especially over age 85)
• Coronary arteries incompatible with grafting

Contraindications to a heart transplant include:

• Active infection or cancer
• Advanced liver or kidney disease
• Recent stroke or pulmonary embolism
• Poorly controlled diabetes mellitus
• Untreated peripheral artery disease
• Severe lung disease or pulmonary hypertension
• Morbid obesity
• Psychosocial issues (e.g., poor adherence to taking medications or active smoking or drug use)

Contraindications to a heart valve repair or replacement surgery depend on the valve being operated on.

Relative contraindications to mitral valve surgery, for example, include:

• Aortic calcification
• Right ventricular dysfunction
• Severe mitral annulus calcification
• Severe left ventricular dysfunction
• Severe emphysema or restrictive lung disease
• Severe pulmonary hypertension

Potential Risks

Besides general surgical risks like bleeding, infection, blood clots, and an adverse reaction to anesthesia, specific risks associated with open heart surgery include:

• Abnormal heart rhythm (arrhythmias)
• Acute kidney failure 
• Injury to organs (e.g., heart, liver, lungs, etc.)
• Acute pancreatitis
• Memory loss (more common in patients over the age of 65)
• Cardiac tamponade
• Stroke
• Death
• Failure of the donor heart (if the patient underwent a heart transplant)
• Coronary allograft vasculopathy (when the coronary artery becomes thick and hard after a heart transplant)

Purpose of Open Heart Surgery

Open heart surgery is used to treat a number of different heart conditions.

Coronary artery disease (CAD), the most common indication, occurs when fatty clumps (plaques) clog the arteries that supply blood to the heart muscle. This results in reduced blood flow to the heart. If the blockage is significant, angina, trouble breathing, and, in some cases, a heart attack may occur.

Open heart surgery may also be used to:

• Treat end-stage heart failure
• Treat refractory heart arrhythmias, including atrial fibrillation (called the Maze heart procedure)
• Repair diseased/damaged heart valves
• Repair congenital heart defects
• Treat cardiomyopathy (enlarged heart)
• Implant a medical device, like a left ventricular assistive device (LVAD)
• Transplant a heart

The benefits of open heart surgery are often immense and can include:

• Alleviating or reducing symptoms like chest pain or trouble breathing
• Decreasing the risk of cardiovascular conditions like stroke or heart attack
• Improving survival and quality of life

Several different pre-operative tests are performed before a patient undergoes open heart surgery.

Examples of these tests include:

• Blood tests, such as complete blood count (CBC) and a coagulation panel
• Electrocardiogram (ECG or EKG)
• Echocardiogram
• Cardiac stress test
• Cardiac catheterization
• Pulmonary function tests
• Psychological and social evaluation (for a heart transplant)

How to Prepare

Once an open heart surgery is scheduled, your surgeon will give you specific instructions to follow.

These may include:

• Avoid chewing, eating, or drinking anything (including water) after 10 p.m. on the eve of your surgery.
• Avoid caffeine and alcohol up to 48 hours before surgery.
• Shower with a special antibacterial soap starting two to four days prior to surgery.
• Stop smoking and/or tobacco use as soon as possible.
• Cease or continue certain medications prior to surgery.
• Undergo several vaccinations (applicable only to patients undergoing a heart transplant).

What to Expect on the Day of Surgery

Prepping you for surgery will involve several steps, including checking your vitals, placing an IV in your hand, arm, or neck to deliver fluids and medications during surgery, and placing an arterial line (a thin catheter that goes in an artery in your wrist) to monitor your blood pressure.

Once you are in the operating room, an anesthesiologist will give you medications to put you to sleep and a breathing (endotracheal) tube will be inserted. This tube is connected to a ventilator to assist with breathing during surgery.

A Foley catheter will also be placed at this time to drain urine. In select cases, the surgeon may place a thin tube called a Swan-Ganz catheter in a vein in your neck. This catheter measures pressures in and around the heart and is used for monitoring purposes during and right after surgery.

The precise steps of your open heart surgery depend on what exactly is being done (valve repair, heart transplant, coronary artery bypass, etc.) and what technique is being used.

That said, here is a general breakdown of a traditional open heart surgery:

• Access: The skin over your chest will be cleaned, the surgeon will make an 8-inch incision down the center of the chest wall, and then cut your breastbone in half lengthwise. The breastbone will be separated from your ribs and spread apart to expose the heart.
• Operating on the heart: You will be placed on a heart-lung bypass machine. Then, depending on the operation, various steps will be performed. For example, one or more blocked coronary arteries may be bypassed during a CABG. A diseased valve may be removed and replaced with an artificial valve during a valve replacement.
• Completion: The surgeon will remove you from the bypass machine to allow blood flowing through it to re-enter your heart. Temporary pacemaker wires placed during surgery (if applicable) will be attached to the device outside your body. The breastbone will then be sewn back together with small wires. Chest tubes may be placed to drain blood and other fluids around the heart. Muscles and skin are then closed with sutures. A sterile bandage will be applied over the large incision site.

You will be wheeled into a post-anesthesia care unit (PACU) where you will wake up from anesthesia.

Recovery

The breathing tube placed at the start of surgery will not be removed until you are fully awake from anesthesia. You will not be able to speak while it is still in place, but you will be able to answer questions by nodding your head "yes" or shaking your head "no".

As you wake up in the PACU, you will notice the various other tubes and machines placed during surgery.

Tubes placed in your chest during surgery will drain red or pink-colored fluid into a plastic container located on the side of your bed. You will also notice that the Foley catheter placed in your urethra is draining urine into a bag located at the foot of your bed.

If a temporary pacemaker is being used, you'll see thin wires emerging from the skin on your chest that are connected to an external machine. A thin tube will be sticking out of your neck if a Swan-Ganz catheter was placed.

Transition to Critical Care Unit

Once your vital signs are stable, you will be moved from the PACU to a cardiac, surgical, or transplant intensive care room. This critical care environment is necessary to provide you with one-on-one nursing care and constant monitoring.

In your intensive care room, you can expect the following to occur:

• Your breathing tube will be removed when you are fully awake. Supplemental oxygen may be given by the nose to assist breathing.
• Your chest tube(s) will be removed once the drainage slows down (usually within one to three days after surgery, but sometimes longer).
• If temporary pacemaker wires or a Swanz-Ganz catheter were placed, they will be removed around the second or third day after surgery.
• Although you may not have much of an appetite after surgery, you will begin drinking clear liquids.

During your recovery, you will also be given various medications to manage common symptoms after surgery, like pain, constipation, and nausea. You may also be given medications to prevent blood clots, maintain normal blood pressure, or to remove excess fluid from your body.

Patients undergoing a heart transplant will begin taking immunosuppressants right away to prevent their immune system from rejecting their new heart.

Transition to a Hospital Room

When ready, you will be moved from an intensive care room to a regular hospital room. Here, your Foley catheter will be taken out, and you will start performing leg exercises and getting out of bed. You will also slowly advance your diet from clear liquids to a low-fat, low-sodium diet.

The surgical team will then help you get ready to go home or to a rehabilitation facility (to regain strength after surgery). You will be given instructions on how to minimize pain and protect your surgical wound site.

More specific at-home recovery instructions and follow-up will depend on the type of open heart surgery you underwent.

Long-Term Care

Ongoing care is essential to maintaining the benefits of open heart surgery.

You can expect to have multiple check-ups with your surgeon and cardiologist. During these visits, you may have blood tests, an EKG, and/or a stress test. These tests will show how well your heart is working after the surgery.

Your cardiologist will also recommend adopting or maintaining healthy lifestyle habits, such as quitting smoking, eating nutritiously, and managing underlying health conditions like diabetes, high blood pressure, and high cholesterol.

You will also be given guidance on how to safely and effectively increase your activity after surgery. Your cardiologist may refer you to an outpatient physical therapy program. A physical therapist can help you devise an individually-tailored exercise program.

If you underwent a CABG, your surgeon will refer you to cardiac rehabilitation, which is a medically supervised program that helps improve the health and well-being of people who have heart problems. Cardiac rehabilitation includes exercise training, education on heart-healthy living, and counseling to reduce stress and help you recover.

A Word From Verywell

Open heart surgery is a major operation that can be life-altering and even life-saving. That said, surgery is oftentimes not a cure. Patients must be incredibly devoted to their surgical aftercare and rehabilitation to optimize their chances of having a forever-healthy heart.

If you or a loved one are undergoing open heart surgery, remain proactive in learning everything you can about your surgery. Also, be sure to reach out to friends and family for support as you navigate this understandably stressful time.