Open Heart Surgery: Overview

Open heart surgery is any type of surgery that involves opening up a person's ribcage through a large chest incision in order to expose their heart. This major operation 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 rigorous. After surgery, patients must be firmly committed to their follow-up care and heart-healthy lifestyle habits.

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 patient's breastbone (which is connected to the ribcage) is then cut in half lengthwise and spread apart in order to expose the heart located 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—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—called a coronary artery bypass graft (CABG). 

Open heart surgery may also be done to:

• Repair or replace diseased heart valves
• Repair a congenital heart defect
• Treat atrial fibrillation (called the Maze heart procedure)
• Transplant a heart
• Implant a medical device, like a left ventricular assistive device (LVAD)

Various Surgical Techniques

Open heart surgery is an umbrella term for any operation that entails opening up the chest to expose the heart.

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 techniques have emerged.

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 (called "off-pump" surgery).

There are also minimally invasive valve repair or replacement techniques. With minimally invasive mitral valve surgery, 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, for example, to mitral valve surgery 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 (causing symptoms like chest pain and trouble breathing) 
• 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. Most commonly, it is used to treated coronary artery disease (CAD).

Coronary artery disease occurs when fatty clumps (plaques) clog the arteries that supply blood to the heart muscle. This clogging 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
• Refractory heart arrhythmias
• Diseased or damaged heart valves
• Congenital heart defects
• Cardiomyopathy (enlarged heart)
• Implant medical devices (e.g., an LVAD), often as a bridge to heart transplant

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)
• 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 instructions 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

Upon arrival at the hospital on the day of your operation, you will first go to a pre-operative room where you will change into a hospital gown.

After recording your vitals, a nurse or surgical assistant will place an IV in your hand, arm, or neck (called a central line) to deliver fluids and medications during surgery. An arterial line (a thin catheter that goes in an artery in your wrist) will be placed to monitor your blood pressure.

You will then wait in a holding area with your loved ones. When your surgical team is ready, you will be wheeled into the operating room (OR) on a gurney. Your loved ones will wait for you in a comfortable waiting room. A hospital staff member or member of the surgical team will provide them with updates during the surgery.

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 to drain urine will also be placed.

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

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

1. Skin Incision: After the skin over the chest is cleaned with an antiseptic solution, the surgeon will make an 8-inch skin incision down the center of your chest wall.
2. Breastbone Incision and Separation: Next, the surgeon will cut your breastbone (sternum) lengthwise in half. Your breastbone (which is connected to your ribs by cartilage) will be separated and spread apart in order to expose the heart.
3. Connected to Heat-Lung Bypass Machine: Once your heart is exposed, you will be placed on a heart-lung bypass machine.
4. Specific Steps: Depending on the operation, various steps will be performed. For instance, with coronary artery bypass surgery, the surgeon will harvest and place a graft. Harvesting involves removing a portion of a healthy blood vessel from another part of the patient's body (e.g., a vein from the leg or an artery from the wrist) and then sewing the graft into a small opening below the diseased artery. With a heart transplant, a diseased heart is removed and replaced with a healthy donor heart. With a heart valve replacement, a diseased valve is removed and replaced with an artificial valve.
5. Removal of Heart-Lung Bypass Machine: Once the surgery is complete, the surgeon will allow blood flowing through the bypass machine to re-enter your heart. The heart usually begins beating on its own; sometimes, the surgeon will need to give the heart mild electric shocks to get it started again.
6. Placement of Temporary Pacemaker Wires: Your surgeon may place temporary, thin wires onto the surface of your heart during surgery. These wires are then attached to a pacemaker outside your body.
7. Closure: 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.
8. Prep for recovery: You will be wheeled into a post-anesthesia care unit (PACU) where you will wake up from anesthesia. Of note, the breathing tube placed at the start of surgery will not be removed until you are fully awake from anesthesia.

Recovery

As you wake up in the PACU, you will notice that you are attached to various tubes and machines.

These tubes/machines include the following:

• Breathing tube: You will not be able to speak with a breathing tube. However, you will be able to answer questions by nodding your head ("yes" or "no").
• Chest Tube(s): Tubes in your chest (placed during surgery) will drain red or pink-colored fluid into a plastic container located on the side of your bed.
• Pacemaker Wires (if applicable): Thin wires will emerge from the skin on your chest and be attached to a pacemaker located outside your body.
• Swan-Ganz catheter: A large IV called a Swan-Ganz may be placed in your neck after surgery to help the surgical team monitor critical heart functions and infuse medications.
• Foley catheter: A catheter placed in your urethra (during surgery) will drain urine into a bag located at the foot of your bed. You may feel an urge to urinate while the catheter is in place.

Once your vital signs are stable, you will be moved from the PACU to a cardiac, surgical, or transplant intensive care room. The 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 systems from rejecting their new heart.



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

The benefits of open heart surgery are often immense and include alleviating or reducing symptoms like chest pain or trouble breathing, decreasing the risk of cardiovascular conditions like stroke or heart attack, and improving survival and quality of life. That said, ongoing care is essential after surgery to maintain these benefits.

After surgery, you can expect to have multiple checkups with your surgeon and cardiologist. During these visits, you may have blood tests, an EKG (electrocardiogram), echocardiography, 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, being physically active, and managing underlying health conditions like diabetes, high blood pressure, and high cholesterol.

You may also undergo 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-saving, if not life-altering. 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.