What is Open Heart Surgery?
Traditionally, open heart surgery meant the breastbone being cracked open, providing direct access to the heart, allowing heart surgeons to fix heart problems while the patient is placed on a heart lung machine. Open heart surgery is probably the most widely known and feared of all operations, but in the right hands open heart surgery can be remarkably safe and effective, associated with excellent outcomes for patients. Read here to learn about robotic heart surgery.
Modern approaches mean that open heart surgery has been revolutionized and is now an entirely different prospect compared to what it used to be. In expert centers, particularly for valve surgery, there is now the routine use of minimally invasive techniques meaning incisions are getting smaller and smaller. Certain heart surgery cases may even be done using robot assistance where the entire case is done without any major incisions at all.
Excitingly, the rapidly expanding field of structural heart disease is realizing the dream of repairing heart defects without the need for any chest incisions whatsoever meaning that the future of open heart surgery may be no open-heart whatsoever!
What are Some Types of Open Heart Surgery?
The most well known open heart surgery is bypass surgery, often known as CABG (coronary artery bypass surgery). That is done to bypass heart blockages. Other well known open-heart surgeries include heart valve repair and replacement, surgery on the aorta , surgery for holes in the heart and heart transplant surgeries. Artificial heart pumps (known as VAD short for ventricular assist devices) are also often placed by means of open heart surgery. In children and adults that have been born with major abnormalities (known as congenital heart disease) multiple open heart surgeries may be required over a life time.
Who Performs Open Heart Surgery?
Open heart surgery is performed by heart surgeons, also known as cardiac surgeons. To become a cardiac surgeon a significant amount of training is required. After medical school, there is 5 years of residency training then 2 years of training in cardiac surgery. Often an extra year will be done to super specialize in certain areas or to develop extra skills. It often takes many years before surgeons become experienced enough to perform independent, highly complex open heart operations.
The History of Open Heart Surgery
Prior to the 1950’s adult heart surgery was limited to procedures that were performed for rheumatic mitral valve disease. These procedures, although working on heart valves, did not need the heart lung machine and were relatively simple. The reason that more complex operations were not done is because in order to perform complex heart surgery, the heart would need to be stopped and a heart lung machine would need to take over. This was not developed until the 1950’s. In 1952, after spending 20 years developing the heart lung machine, Dr John Gibbon performed what is considered the first successful open heart operation for a large hole in the heart. Since that time the field has advanced incredibly to where we stand today.
Descriptions of Different Open Heart Surgery Operations
Coronary bypass surgery is performed to treat blockages in heart arteries. It is the most common open heart surgery. In this operation arteries and/or veins are used to bypass the blockage and improve the blood supply to the heart. The arteries can be taken either from inside the chest wall, or the arm. The veins are typically taken from the leg. In most cases the patient is placed on the heart lung bypass machine and the heart stopped. There are some surgeons who prefer to perform the operation with the heart beating and therefore no need for the heart lung machine. The best approach is controversial and depends on the center used. The mini videos throughout this post are taken from a bypass operation.
Heart Valve Surgery
There are four valves in the heart. These are called the mitral valve, aortic valve, tricuspid valve and pulmonic valve. These are described in more detail in this linked article. Heart valve repair and replacement is conventionally performed with the use of the heart lung machine. In valve repair, the diseased valve is fixed by making adjustments to the existing valve. In valve replacement the valve is simply cut out and a new either tissue or metallic valve is sewn in. In many cases, in patients with artery blockages, bypass surgery can be performed at the same time as valve surgery.
The aorta is the large blood vessel that leaves the heart and supplies the body with blood. Surgery can be required for aortic aneurysms or more emergently for aortic dissections. Heart surgeons operate on the aorta when it is in the chest. Vascular surgeons operate on the aorta once it is in the abdomen. Aortic surgery needs to be done by experts and very carefully as the vessels that leave the aorta supply the brain and spine.
Heart Transplant Surgery
In heart transplant surgery, the diseased heart is literally removed and a new heart sewn in to place. The new heart of course needs to be attached carefully to the blood vessels of the body. Dedicated heart transplant surgeons who are also responsible for retrieving the donor hearts perform transplant surgery. Transplant surgeons are also responsible for placement of artificial heart pumps known as VAD’s short for ventricular assist devices. VAD’s can do the work of the heart when the heart fails. Progress continues to be made in what is known as the total artificial heart.
Other Heart Surgery
Myomectomy – A procedure known as myomectomy is performed for a condition called HOCM that stands for hypertrophic obstructive cardiomyopathy. In that condition thick heart muscle gets in the way of blood trying to leave the heart. In the operation the thick tissue is cut out.
Septal Defect Repair – Holes in the upper and lower chambers of the heart known as atrial septal defects and ventricular septal defects are often repaired by means of open heart surgery. Often patches are placed over these holes to cover them.
Pulmonary Embolectomy and Endarterectomy – Clots known as pulmonary embolism can form in the lung and lead to right sided heart failure and dangerously high lung pressures. In a procedure known as embolectomy, clots can be removed as an emergency. Sometimes these clots accumulate over time and become hard and fixed to the blood vessels of the lung. They can be removed in a complex operation known as a pulmonary endarterectomy. This complex operation is only performed by a handful of surgeons.
Open Heart Surgery – What to Expect as a Patient
Diagnosis – Most patients will see a cardiologist first who will diagnose their problem based on their story, physical exam, and tests. Multiple tests may be required including echocardiograms, CT scans, and a heart catheterization. Once the diagnosis and the need for open heart surgery have been determined then the patient is referred to a cardiac surgeon for an evaluation.
Meeting the Surgeon – Surgeons will often be suggested by the cardiologist depending on their referral patterns however often patients will select their own surgeons based on other recommendations or their own research. Once this is decided the patient will go and meet the surgeon in clinic. Here the surgeon will talk with the patient and review the testing. Based on this meeting a surgical recommendation can be made and operative risk and suitability can be determined. In many cases the surgeon may ask for further testing to be performed.
Meeting the Anesthesiologist – When undergoing open heart surgery patients will be put to sleep, which is known as being under general anesthesia. Of course this is so patients will not feel anything or be aware of what’s happening. Before the surgery the anesthesiologist will meet the patient, take a careful history and determine the risk of anesthesia and the best method of delivering it. In some places there are special clinics known as pre-op clinics that patients attend. In other places the patient will meet the anesthesiologists the night before, or the morning of surgery.
Getting Ready for the Operation – Patients will be dressed in a gown and taken to the operating room there they will lay on the operating table. Here the patient will be prepared for open heart surgery with meticulous detail using sterile techniques to prevent infection. The chest will be shaved in the case of men. The chest will then be cleansed with disinfectant and a thin wrap be placed over the chest. The anesthesiologists will place IV lines and arterial lines to be used for pressure monitoring and drug delivery during the case. A breathing tube will then be placed in the patient, and the ventilator machine will take over breathing until the patient wakes back up.
Details of the Operation
Making the Incision – In the case of classic open heart surgery, the breast bone will be split open using a saw. Alternative approaches may use incisions to the side of the bone between the ribs or through some of the ribs on the side. In robotic heart approaches, no large incisions are made, and small tubes are inserted through which the operation is performed, sometimes called keyhole surgery.
Cardiopulmonary bypass – This is also known as going on the heart lung machine. The machine takes over the work of the heart and the lungs, while the heart is stopped using a technique known as hypothermic cardioplegia, which is essentially infusion of a cold solution into the coronary circulation to stop the electro-mechanical activity of the heart. Tubes known as cannulas are placed in the heart and the great vessels of the body and the blood is drained through and pumped back in to the body through these tubes. In some cases the heart lung machine is not used, these are called off-pump cases. In those cases the operation is performed on the beating heart.
The Operation Itself – In bypass surgery, one by one the blocked arteries will be bypassed using vein or artery taken from elsewhere; these are sewed into place delicately. In the case of valve replacement the old valve is cut out and a new valve sewn in. In valve repair, different techniques are used to repair the existing valvClosing the Chest – After the operation is complete on the heart, the patient is weaned off the heart lung bypass machine and the heart is restarted with an electrical shock. Then the chest incisions are sewn together. In the case of the breastbone, wires known as sternal wires are placed to hold it together until it heals.
After the Operation
Transport to the ICU – After the operation is complete, the breathing tube will be left in place and the patient transported to the intensive care unit. There will be several drains in place from around the heart and the chest to allow blood to drain. The breathing tube is typically taken out a few hours after the operation and the drains taken out over the next few days.
Post-operative Recovery – A lot of this depends on the patient. Of course a sick 85 year old will in general have a tougher time than a relatively healthy 45 year old. Early sitting in a chair and walking is encouraged and physical therapists will often work with patients to ensure a timely recovery. Patients are expected to walk up and down the halls easily prior to being discharged. Breathing exercises are encouraged to allow the lungs to return to normal functioning.
Discharge – Most patients are discharged within the week of an open-heart operation. Patients who are not well enough to return home may be discharged to a rehab facility for a short while to enhance their recovery.
Return Visit – Most patients will come back and see the heart surgeon 1-2 weeks after the operation. Remaining stitches can be removed and any issues discussed. Patients will usually see their cardiologist a month after any procedure also.
Open Heart Surgery – Patient Risk
The risk of open heart surgery to any patient is very dependent on the patient themselves and how sick they are. Of course a healthy 45 year old is going to have a lower risk than an 85 year old. Several risk factors have been found to be important when determining the risk for any given patient.
Age – Older patients are in general at higher risk than younger patients.
Sex – In general female patients have higher risk than make patients.
Obesity – Obese patients are at higher risk.
Heart Function – Pumping function of the heart is important; those with impaired heart pumping function are at higher risk.
Kidney Function – Patients with impaired kidney function have higher risk; the worse the kidney function the higher the risk.
Heart Attack – Those that have had a heart attack are at higher risk, particularly if the heart attack is around the time of surgery or if there are active symptoms of chest pain at the time of surgery.
Lung Disease – Those with known lung disease, such as COPD, are at higher risk; the worse the lung disease the higher the risk.
Emergency Surgery – Surgery that needs to be performed emergently due to active symptoms, or instability carries a much higher risk than elective planned surgery.
Presence of Multiple Problems – The more issues that need fixing, the higher the risk; for example someone needing a simple bypass operation is lower risk than someone needing a bypass and 2 valves fixed at the same time.
Number of Previous Surgeries – The more surgeries someone has had, the higher the risk. This is due to build up of scar tissue and other issues that arise with each open heart surgery operation.
by Dr. Mustafa Ahmed