Triple Bypass Surgery: Overview

Triple bypass surgery, also known as coronary artery bypass graft (CABG) surgery, is the most common type of heart surgery performed on the adult population. Through the utilization of an open chest technique, surgeons transport three vessels to the heart and surrounding area to bypass the damaged vessels.

People need this surgery after the coronary arteries become blocked or damaged as a result of the build-up of fatty deposits known as plaque. As a result, the coronary arteries can not carry enough blood and oxygen, which can lead to a heart attack or stroke.

Through a triple bypass surgery, the vessels are replaced and the blood is able to flow freely through the blood vessels.

Team of surgeons operating on patient in hospital - stock photo

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What Is Triple Bypass Surgery?

Triple bypass surgery, is the grafting of three vessels from the body, to be used to bypass damaged areas of the heart in order to improve oxygenation. This surgery is performed by a team of skilled cardiovascular surgeons while inpatient in the hospital.

This procedure is done strictly as an inpatient surgery and can be either done as an emergency surgery or a scheduled surgery. However, if the surgery is scheduled it is always considered time-sensitive.

The surgery is performed on patients who have coronary artery disease, which causes arteries to become narrowed and hardened in a process called atherosclerosis. This process usually occurs in adults; however, it can occur in children.

Triple bypass surgery requires the grafting of three blood vessels to bypass the damaged areas. Blood vessels can be taken from your leg (saphenous vein), inside your chest (internal mammary artery), or your arm (radial artery). The specific vessel used will be determined by the surgeon.

After the vessels have been grafted they are placed into the appropriate areas of the heart and then the heart is closed using sutures and metal wires. If the procedure is done on-pump the heart is restarted using controlled electrical shocks.

Various Surgery Techniques

Triple bypass surgery is typically performed via an open heart procedure which means a surgeon will cut the chest open with a vertical incision to access the heart. Surgery typically lasts from three to eight hours, depending on how difficult the grafts are to access.

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 doctors to stop the heart.

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 is a more difficult surgery to perform because of its technical precision but the preferred approach for some surgeons.

According to the National Institute for Health and Care Excellence (NICE), the procedure 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 total CABG procedures were performed using off pump, while the remainder of surgeons performed the procedure on pump. The on-pump technique requires additional training and it was found that the older generation of cardiothoracic surgeons prefers on pump technique.

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.

Utilizing a hybrid approach allows for minimally invasive surgery while still correcting the underlying issue. Individuals will have a small midsternal incision, a shorter hospitalization and recovery time as well as decreased associated risks.

While a hybrid approach may seem ideal, there are strict requirements as to what patients qualify for this procedure. These include:

  • A blockage in a major vessel called the left anterior descending (LAD) artery, which supplies 60% of the blood to the heart
  • Blockages in non-LAD arteries that can be treated with a stent

Contraindications

Triple bypass surgery is contraindicated in a specific population including:

  • Age: Risk increases in the younger and older population
  • 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 (i.e. triple 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

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

There are numerous factors that can increase an individuals risk of complications after the surgery. These factors may 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 with your doctor the risks associated with surgery as the benefits of surgery may outweigh the risks.

Purpose of Triple Bypass Surgery

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 ultimate purpose of a triple bypass procedure is to deliver oxygen to the heart, other purposes 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 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 the risk for stroke
  • Decreasing arrhythmias

How To Prepare

Preparing for surgery is never easy. It can be a scary and uncertain time for the patient and their families. After initial appointments the surgeon will give the patient a list of instructions that need to be followed and/or studies that need to be completed.

The night before the surgery, a preoperative registered nurse will call the patient to go over the scheduled arrival time and any last-minute instructions. These instructions will include what medications should be held prior to the procedure as well as what time to become NPO (nothing by mouth).

Patients must not eat or drink anything for a specific number of hours before the procedure. Specifics regarding the time of NPO status will be discussed with your healthcare provider prior to the surgery.

Patients will need to undergo several tests prior to triple bypass surgery. These may include:

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

What to Expect of the Day of Surgery

Patients should expect to stay in the hospital for approximately seven days after the surgery. Patients report to the hospital at the prescheduled arrival time and will be instructed to change into a hospital gown. It is helpful to have someone at the hospital for support.

The patient can expect to meet with a member of the anesthesia team as well as the surgical team to go over the procedure as well as sign consent forms. Patients can expect to give a urine specimen, specifically women who are required to have a pre-surgical urine pregnancy test.

Intravenous (IV) access is obtained for the procedure in order to deliver anesthetics, medications including pain medication and antibiotics, and blood products. Patients should expect to spend to spend a minimum of one to two days in the intensive care unit.

Surgery

The surgery itself typically lasts three to five hours; however, a triple bypass surgery tends to run on the longer end because of the grafting of three separate and distinct blood vessels.

Once the patient has been prepared in the preoperative area, patients are taken to the operating room and place under general anesthesia. During this time, a breathing tube is inserted into the mouth and lungs in order to allow the patient to breathe safely during the procedure. The tube is connected to a ventilator that helps the patient breathe.

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

After the surgical area is prepped, the three vessels are harvested from the arms and/or legs to be used to bypass the damaged vessels surrounding the heart. A midsternal incision and the breastbone and ribcage are spread to provide access to the heart and surrounding vessels.

At this time, the surgeon will either stop the patient's heart to perform the surgery or continue to allow it to beat throughout the procedure. The damaged vessels are removed and the new healthy vessels are grafted. At this point blood flow is restored to the heart.

The surgeon(s) will continue to 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.

Recovery

Recovery after triple bypass surgery is a slow process and can take weeks to months depending on the patients age, pre-exisiting conditions, overall health, as well as a variety of other factors. A patient's recovery can be partially dependent on an individuals motivation. Recovery after triple bypass surgery 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:

  • Healthy diet, including a diet high in omega-3 fatty acids and low in saturated and trans fats
  • Smoking cessation
  • Engaged in a healthy lifestyle
  • Decrease stress, anxiety, and depression
  • Control high blood pressure and high cholesterol
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Article Sources
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  1. National Institute for Health and Care Excellence. Off-pump coronary artery bypass grafting: Interventional procedures guidance [IPG377]. January 26, 2011.

  2. iData Research. Cardiac surgery market analysis, size, trends | United States | 2020-2026 | COVID19 | MedSuite. October 8, 2020.

  3. University of Maryland Medical Center. Hybrid coronary intervention.