Heart surgery may seem like one of the most daunting treatments you can have. After all, the heart is the powerful machine that keeps your body running. If you live to be 80, it will beat more than 3 billion times. But, while heart surgery is serious, you may find it reassuring to know that it’s also a field that has attracted some of surgery’s greatest pioneers—and their innovations have made routine work out of treating conditions that would have once been fatal.
Thousands of heart surgeries are performed every day in the United States. Many patients have excellent results—not only do patients survive longer than they used to, they enjoy a good quality of life.
“One of the most gratifying things we see in heart surgery is when an operation changes a patient's life,” says Arnar Geirsson, MD, chief of cardiac surgery for Yale Medicine. “While an operation’s success depends on many factors, the most important thing I've learned is that the heart is resilient and so are patients. Sometimes, you can take people who are very, very sick and turn things around dramatically.”
Why would I need surgery?
Heart surgery may be a consideration if you have a heart problem, and lifestyle changes, medication, noninvasive medical procedures, and other surgeries aren’t helping you get better. In some cases, your doctor will recommend heart surgery to treat a problem before it becomes critical. In others, it will be an emergency procedure to treat a condition that has become urgent, such as advanced blockage in a coronary artery.
There are many reasons why you might need heart surgery. Here are four common ones:
- A blocked coronary artery: Coronary artery bypass grafting (CABG) is the most common heart operation cardiac surgeons perform. If one of the coronary arteries that supplies blood to the heart is blocked or diseased, the surgeon will take a healthy section of blood vessel from another part of the body and use it to bypass the damaged vessel. This operation may be referred to as a single, double, triple, or quadruple bypass, depending on how many arteries the surgeon is working to bypass.
- An aortic aneurysm: The aorta is the main artery in the body—its job is to carry oxygenated blood from the heart, down into the chest and torso, and to supply that blood to the body. Genetics or other factors can cause a small section of the artery walls to thin and weaken, causing a dangerous balloon-like bulge, or aortic aneurysm, to develop. As a result, the weakened section of the aorta needs to be replaced to prevent rupture or dissection. Typically, a traditional open surgery will be done, but, in some cases, a minimally invasive procedure that uses a stent, or small tube, to support the weak artery wall may be appropriate.
- A faulty valve: The heart has four valves that open every time the heart beats to let blood through, then close to prevent the blood from flowing back. When a valve is narrowed or isn’t opening and closing properly, surgery can be used to repair or replace it. Valve replacements may be made using biological valves made from animal tissue, or from man-made mechanical valves.
- Heart failure: Heart transplant surgery is a last resort for people with heart failure. The surgeon opens the chest, removes the diseased heart, and replaces it with a donor heart. Alternatively, in some cases, a surgeon may recommend a ventricular assist device (VAD), which involves surgically implanting a small mechanical pump to help the heart pump blood to the body until a donor heart becomes available—or as a permanent solution in some cases.
How is heart surgery done?
There are variety of approaches to heart surgery:
- Open surgery: The surgeon makes an incision down the front of the chest, then cuts through the breastbone to get to the heart. The patient breathes with the help of a breathing tube connected to a ventilator and is connected to a heart-lung machine that takes over the heart’s pumping action to keep blood circulating throughout the body. This allows the surgeon to perform the operation on a heart that remains still.
- Off-pump heart surgery: This is also called beating heart surgery, and it is used for CABG surgeries in some patients. Off-pump surgery doesn’t use a heart-lung machine. Instead, the surgeon uses a tissue stabilization system to immobilize the area of the heart where they plan to operate while the rest of the heart continues to pump.
- Minimally invasive heart surgery: Small incisions are made inside of the chest so that the surgeon can work between the ribs. Minimally invasive heart surgery may (but does not always) require the use of a heart-lung machine. Surgeons use this approach for a variety of procedures, including bypass surgery, and aortic and mitral valve replacements. Surgeons evaluate patients to determine whether they are candidates for minimally invasive surgery.
- Robotic heart surgery: A cardiac surgeon performs this minimally invasive type of surgery while sitting at a computer console, where he or she can manipulate robotic arms to control the surgical instruments. The approach offers better precision for surgeons and smaller incisions and higher satisfaction for patients, says Dr. Geirsson. Surgeons evaluate patients to determine whether they are candidates for robotic heart surgery.
- Transcatheter heart surgery: Various procedures on the heart can be performed using catheters that are placed through a small puncture in the groin. This includes transcatheter aortic valve replacement (TAVR), repair of mitral valve with Mitraclip, or closure of defects in between chambers of the heart.
What does a heart-lung machine do?
Operating on a heart safely while it is beating is difficult. A heart-lung (or cardiopulmonary bypass) machine takes over the function of maintaining the circulation of blood and oxygen throughout the body so that the surgeon can work on a still heart. This process is called perfusion, and it is managed by perfusionists. These machines can take over the heart’s pumping action for hours.
What is heart surgery like?
Because there are many types of heart surgeries, one patient’s experience may be dramatically different than another’s. A patient may be asked to undergo tests before surgery, such as a chest X-ray or an electrocardiogram (EKG). Typically, the surgeon will want the patient to stop taking any blood-thinning medications, and stop smoking and possibly drinking alcohol in the weeks before surgery.
A team of specialists, including cardiac surgeons, anesthesiologists, and operating room nurses, will work together to perform surgery. The length of surgery will vary. CABG typically takes three to six hours, while the implantation of a VAD can take several hours, depending on the severity of the condition and such factors as scar tissue from previous operations, which can make the surgeon’s work more complex.
Depending on the surgery—especially if it’s open heart surgery—the patient is usually given general anesthesia and will remain asleep through the procedure. He or she may wake up attached to machines that monitor the heart, as well as tubes in the chest to drain fluid from around the heart. Some patients, including those who have surgeries to implant pacemakers, may go home the next day. Others will start their recovery in the intensive care unit, followed by several days in the hospital.
Pain may linger in the chest and muscles, but this goes away eventually. Some patients are referred to medically supervised cardiac rehabilitation programs.
How successful is heart surgery and what are the risks?
Risks associated with heart surgery include infection, irregular heartbeat, and bleeding—as well as such serious problems as heart attack and stroke. Older people, women, and those with serious diseases, such as diabetes or lung disease, are at higher risk for complications.
But surgeons using the latest techniques, technologies and approaches often have excellent results, even for many high-risk patients.
How is Yale Medicine unique in its approach to cardiac surgery?
Yale Medicine Cardiac Surgery has a team of world-class heart surgeons who are highly skilled in treating the full range of cardiac diseases and conditions, using a variety of approaches and techniques, from minimally invasive robotic surgeries to complex open surgeries. Yale New Haven Hospital’s Heart & Vascular Center is one of the few cardiac centers in the country where cardiac surgery outcomes for procedures such as CABG and mitral and aortic valve replacement consistently exceed national and regional norms.
Yale is a major referral center for a number of cardiac surgeries. Yale Medicine has the largest volume of aortic cases in Connecticut and is in the top 3 percent of aortic surgical volume nationally. We are one of the highest volume centers in New England for mitral valve repairs, which our surgeons can often perform with a minimally invasive approach that may include use of a highly advanced robotic surgical tool. (Yale is the only center in New England to offer robotic mitral valve repair.) We also are nationally recognized for excellence in TAVR and are a designated training center for this technique.
“In the last 15 or 20 years, there have been tremendous advancements in cardiac surgery in general,” says Dr. Geirsson. “It’s not any one particular thing—rather, various things have added up, including technical advances, the team approach to anesthesia, and critical care after the operation.” Yale cardiac surgeons have seen dramatic improvement in their results in that time period, despite the fact that they often treat patients who are advanced in age or have especially complex forms of heart disease, Dr. Geirsson adds.