An Overview of Triple Bypass Heart Surgery

Triple bypass surgery, also known as coronary artery bypass graft (CABG), is the most common type of heart surgery for adults. Three blood vessels from elsewhere in the body are used to bypass damaged vessels of the heart to improve blood flow. Surgery is often done with an open chest technique.

Triple bypass surgery can be a treatment for diseased coronary arteries—the arteries that provide blood to the heart muscles. Coronary artery disease (CAD) occurs due to a build-up of plaque (hardened fatty deposits) that partially or fully obstructs blood flow to the heart muscle—which can lead to exercise intolerance, angina (chest pain), heart attack, and/or heart failure.

Triple bypass surgery is typically successful but recovery after surgery is a slow process and can take about six weeks or more.

What Is Triple Bypass Surgery?

Triple bypass surgery is the grafting of three vessels from the body to bypass damaged arteries of the heart in order to improve heart muscle oxygenation. This is an inpatient procedure that is done by cardiovascular surgeons.

Triple bypass surgery can be done as emergency surgery or as a semi-urgent scheduled surgery.

The surgery is done when atherosclerosis causes plaque buildup and narrowing of the coronary arteries. This process usually occurs in adults; however, it can occur in children.

The blood vessels that are used for the graft can be taken from:

• Your leg (saphenous vein)
• Inside your chest (internal mammary artery)
• Your arm (radial artery).

Your surgeon will determine which vessels to use.

The chest is opened so the vessels can be placed into the appropriate areas of the heart, and then the chest is closed using sutures and metal wires. The procedure may be done with a cardiopulmonary bypass (heart pump) to maintain blood flow throughout the body during surgery.

Purpose of Triple Bypass

The purpose of triple bypass surgery is to surgically treat three blocked or narrowed arteries by bypassing the blocked portion with a piece of a healthy blood vessel from elsewhere in your body.

While the purpose of a triple bypass procedure is to improve blood flow in the heart, benefits include:

• Improving quality of life
• Decreasing angina and other coronary heart disease symptoms
• Ability to resume a more active lifestyle
• Improving the pumping action of the heart if it has been damaged by a heart attack
• Lowering the risk of a heart attack
• Improving chance of survival
• Improving memory function and cognitive skills
• Decreasing arrhythmias
  

Surgery Techniques

Triple bypass surgery is typically performed via an open heart procedure— your surgeon will cut your chest open with a vertical incision to access the heart.

The surgery can be performed "on-pump" or "off-pump". On-pump surgery refers to the use of a heart-lung machine that circulates blood and breathes for the body throughout the surgery. The machine allows healthcare providers to stop the heart during the procedure. If a pump is used, the heart is restarted after surgery using controlled electrical shocks.

The second technique used is off-pump surgery, also called “beating heart surgery.” It is done while the heart is still beating, but does not use the heart-lung machine. This surgery requires more technical precision because of the heart movement, it's but the preferred approach in some situations.

Off-pump surgery can be done with an open chest technique that cuts the breastbone or sometimes with smaller incisions along the ribs.

According to the National Institute for Health and Care Excellence (NICE), off-pump surgery works as well as a coronary artery bypass using a pump. It is a newer technique that has shown some increased benefits including:

• Quicker than the conventional procedure
• Reduces the chance of bleeding during the surgery
• Decreased risk of certain serious complications after surgery, such as a stoke
• Shortened hospital stay

A survey showed that in 2019, approximately 15.8% of CABG procedures were performed using off-pump, while the remainder were done on pump.

Hybrid Approach

A newer technique that is only used at a select few hospitals around the country is a hybrid technique. A hybrid approach includes minimally invasive bypass surgery with catheter-based coronary intervention.

The procedure involves a small midsternal incision and usually results in a shorter hospitalization and recovery time, as well as a reduced risk of associated complications.

There are criteria for this procedure.

These include:

• A blockage in a major vessel called the left anterior descending (LAD) artery, which supplies a large portion of the heart's blood supply
• Blockages in non-LAD arteries that can be treated with a stent

Contraindications

Triple bypass surgery may be contraindicated due to:

• Age: Risk increases with advancing age
• Individuals with preexisting conditions such as diabetes, chronic kidney failure requiring dialysis, cancer, and/or chronic obstructive pulmonary disease
• Obesity
• Having more than three vessels grafted (quadruple or quintuple bypass)
• Immediately after a heart attack

While the aforementioned are potential contraindications to having surgery, it is important to discuss all options with your healthcare provider and/or surgeon.

Potential Risks of Triple Bypass

While all surgical procedures carry risk, those specifically related to triple bypass heart surgery are:

• Infection
• Blood clot
• Heart attack
• Reduced kidney function
• Arrhythmia
• Fever
• Bleeding at incision site
• Stroke
• Memory loss
• Pneumonia
• Breathing difficulties
• Pancreatitis
• Failure of the graft(s)
• Reaction to anesthesia
• Post-pericardiotomy syndrome
• Death

There are numerous factors that can increase the risk of complications after the surgery.

These factors include:

• Age
• Preexisting conditions, including kidney disease, diabetes, liver disease
• Ethnicity
• Gender
• If the surgery is deemed emergent
• Smoking history
• Prior activity level

It's important to discuss the risks and benefits of surgery with your healthcare provider.

How to Prepare

Preparing for surgery is never easy. It can be a scary and uncertain time for the patient and their families.

You will need to undergo several tests prior to triple bypass surgery.

You might need to have one or more of the following:

• Blood tests
• Chest X-ray
• Electrocardiogram (ECG or EKG)
• Coronary angiogram
• Echocardiogram
• Stress test
• Bloodwork including complete blood count, chemistry, coagulation panel

Before your surgery, a preoperative nurse will go over your scheduled arrival time and any last-minute instructions. You will be given instructions regarding whether you need to stop certain medications a few days before your surgery and what time you should become NPO (not eating or drinking anything by mouth) the day before your surgery.

What to Expect the Day of Surgery

You should prepare to stay in the hospital for approximately seven days after your surgery. It is helpful to have someone at the hospital for support for some of this time.

After you check-in, you will go to a preoperative area where you will be instructed to change into a hospital gown.

You will meet with a member of the anesthesia team and surgical team to go over the procedure and sign consent forms. You may be asked to provide a urine specimen.

Intravenous (IV) access is started in the pre-operative area. This will be used for anesthesia, antibiotics, and blood products.

Surgery

You will be taken to the operating room and your general anesthesia will be started. During this time, a breathing tube is inserted into your mouth and lungs to allow you to breathe safely during the procedure. The tube is connected to a ventilator that helps control your breathing.

Throughout the procedure, the anesthesiologist or certified registered nurse anesthetist monitors your heart rate, blood pressure, oxygen levels, and breathing. They also are responsible for providing medication throughout the procedure.

Steps of the procedure:

• After the surgical area is prepped, the three vessels are harvested.
• A midsternal incision and the breastbone and ribcage are opened to provide access to the heart and surrounding vessels.
• At this time, the surgeon will either stop your heart or continue to allow it to beat throughout the procedure.
• The damaged vessels are removed and the new healthy vessels are grafted so that blood flow can be restored to the heart muscle.
• The surgeon(s) will do this for all three vessels.
• Once the surgery is completed, the heart will be restarted (if it was stopped).
• Utilizing wires, mesh, and stitches, the breastbone and skin are closed.

After your surgery, you should expect to spend a minimum of one to two days in the intensive care unit.

Recovery

Your recovery will begin at the hospital. Most people are able to go home about three to five days after leaving the intensive care unit.

After being discharged from the hospital, recovery from triple bypass surgery typically takes about six weeks. Although, it can range from four to 12 weeks since each person progresses at a different rate.

Recovery time varies based on factors such as age, pre-existing conditions, overall health, adherence to guidance from your healthcare team, and any complications.

The recovery process will include:

• Incision care
• Cardiac rehabilitation
• Pain control
• Rest
• Incentive spirometer
• Identifying signs and symptoms of complications
• Follow-up appointments

Long-Term Care

Triple bypass surgery fixes the current problem. However, it does not prevent future plaque build-up or heart attacks. After surgery, it is important to make significant lifestyle changes in order to prevent future complications.

These include:

• A healthy diet, including a diet high in omega-3 fatty acids and low in saturated and trans fats
• Smoking cessation
• A healthy lifestyle
• Reduce stress, anxiety, and depression
• Control high blood pressure and high cholesterol