Surgical Procedure and Intraoperative Measures:
After the patient is transferred to the operating room and placed on the surgical table, the anesthesia team approaches the patient. Once the monitoring leads are attached to both sides of the chest to track the heart rate on the operating room monitor, an intravenous line is established in the superficial veins of the upper limbs using an angiocatheter. Through this line, anesthetic drugs and necessary IV fluids are administered.
This is the only stage during which the patient feels a slight pain; after that, the patient generally experiences no pain. The next step is to establish an arterial line to continuously monitor blood pressure, which is performed under local anesthesia. Afterward, a special mask is placed over the patient’s mouth and nose to deliver oxygen and then inhalational anesthetic agents. At this point, the anesthesiologist administers special drugs to induce full anesthesia and painlessness.
Following anesthesia, the surgical team begins by preparing the vascular grafts required for the procedure. Then, the main part of the surgery — the creation of coronary bypass grafts — begins. In the common and standard method of coronary artery bypass grafting (CABG), a cardiopulmonary bypass machine is used. This device temporarily takes over the function of the heart and lungs, allowing the surgeon to safely stop the heart’s beating and sew the grafts in place. (See section on Cardiopulmonary Bypass.)
In another method, the grafts are sewn without using a cardiopulmonary bypass machine, while the heart continues to beat. The surgeon uses special stabilizing instruments to perform the anastomosis on the beating heart. (For more details, refer to the FAQ section.)
The number of grafts used depends on the extent of coronary artery disease, angiographic findings, and intraoperative observations. The duration of surgery varies but generally lasts 3–4 hours. After the procedure, patients are transferred to the Intensive Care Unit (ICU).
It should be noted that nearly all patients undergoing CABG are transferred to the ICU while still partially anesthetized and connected to mechanical ventilation. Therefore, they are not fully awake or able to communicate with their companions immediately. When the anesthesia wears off and the patient regains consciousness, they will be unable to speak because of a breathing tube inserted into their mouth and trachea. There is no need for concern; patients should remain calm, breathe normally, and know that once their breathing rate and depth reach a satisfactory level, they will be disconnected from the ventilator, and the breathing tube will be removed shortly afterward.
After awakening, many patients feel the urge to urinate, which is usually due to the presence of a urinary catheter (Foley). There is no need for worry or discomfort.
Patients should also be aware that upon waking in the ICU, they will be connected to several devices and monitors — this does not indicate a serious condition, as these are standard monitoring measures for all patients. Intravenous lines are placed in both arms and the neck to administer medications, fluids, or blood products as needed.
Another point of concern for many patients is the presence of chest tubes exiting from their chest, which may contain blood. This is normal; after surgery, several hundred milliliters of blood may collect, and these tubes are essential to drain it and prevent accumulation inside the chest. Mild pain or discomfort at the tube site is normal and should not cause anxiety. Knowing these facts beforehand helps patients remain calm and cooperative during the first few hours after awakening, making postoperative care smoother.
After removal of the breathing tube, patients can breathe comfortably and communicate verbally. They are given small amounts of water, tea, or juice, and usually by the next morning, they can eat breakfast. In the first hours and days after surgery, patients are encouraged to take deep breaths and cough. A simple medical device (incentive spirometer) is given to them to blow into after deep inhalation. These exercises are extremely important because they help re-expand the small parts of the lungs that collapsed during anesthesia and mechanical ventilation, improving oxygenation and preventing postoperative lung infections and fever.
Patients are advised to take this seriously. If they experience pain during deep breathing or coughing, they should place their hand over the chest incision for support and inform the nurse so appropriate pain relief can be provided.
During the ICU stay, before patients get out of bed, it is crucial to move their legs and contract the calf and thigh muscles regularly to prevent deep vein thrombosis (DVT) and related complications. After about two days in the ICU, if there are no complications, patients are transferred to the general ward. At this time, chest tubes are usually removed, surgical dressings are changed, and catheters such as C.V.P. (central venous pressure line) and the arterial pressure line are removed. Patients are then transferred to the ward using a wheelchair.
Approximately 3–5% of open-heart surgery patients may need to return to the operating room due to ongoing, significant, or sudden bleeding, or because of clot accumulation (tamponade) around the heart. This typically occurs within the first six hours after surgery while the patient is still intubated. Such re-exploration should not cause undue anxiety; it does not usually result in additional complications and is often essential for stabilizing circulation.
Mild postoperative bleeding is common and may result from minor leakage at surgical sites or coagulation disorders caused by the cardiopulmonary bypass machine. Continued use of aspirin or Plavix before surgery can also increase bleeding risk.
Postoperative Care in Surgical Wards
Patients who have had an uncomplicated ICU stay are transferred to the general ward and usually no longer require IV medications, except for heparin, which may be administered depending on the individual case. If chest tubes remain, they are typically removed within a day or two.
During surgery, a temporary pacemaker wire is attached to the heart. If heart rhythm slows or conduction problems occur, it can be connected to an external pacemaker generator for temporary pacing. These wires are removed 4–5 days after surgery, a painless procedure.
The surgical wound, located along the middle of the chest (sternotomy), usually no longer requires dressing after the third postoperative day. When special spray dressings are used, no dressing change is needed upon transfer to the ward.
After removing the pacing wires (around day 4 or 5), an echocardiogram is performed to evaluate heart contractility, valve function, and to check for fluid or clots around the heart that might cause compression.
Once all tubes and IV lines are removed and the patient is in stable condition, they may take a shower, resume daily activities, and begin walking several times a day. With the help of the rehabilitation team, patients start light stretching and short-distance walking exercises.
After spending 3–5 days in the ward and ensuring no short-term complications, patients are discharged.
Upon discharge, patients must take their cardiac medications (especially aspirin) regularly, maintain a low-fat, low-salt diet, gradually resume physical activity and walking, and avoid polluted or smoky environments. They should visit their doctor about 3–4 weeks after surgery for follow-up and evaluation of potential mid-term complications.
If patients experience fever, severe weakness, unusual chest pain, swelling in the legs, shortness of breath, redness or discharge from the surgical wound, or any other concerning symptoms before their scheduled visit, they should contact their physician immediately.
Frequently Asked Questions about Coronary Artery Disease
1. In CABG surgery, are the coronary arteries removed and replaced with new ones?
No. In coronary bypass surgery, the blocked coronary arteries are not removed or replaced. Instead, the blocked segment is bypassed — a new pathway for blood is created using a graft from another vessel (usually a vein or artery) that connects the aorta (or one of its major branches) to a point beyond the blockage.
2. What are the advantages of harvesting the leg vein using the endoscopic method?
This method has become increasingly popular in recent years and is now performed in some hospitals in our country. Using endoscopic instruments or small incisions, the required length of the saphenous vein can be removed from the inner leg or thigh. The main advantage is that it eliminates the need for long skin incisions, resulting in better cosmetic outcomes, less pain, and a reduced risk of infection. However, this technique requires proper equipment and experience to avoid vein wall damage. Even though not all centers have this capability, the conventional method remains safe and effective.
3. Is it better to use arterial or venous grafts for CABG?
In general, arterial grafts are structurally more compatible with coronary arteries and have better long-term patency. The internal mammary artery is particularly reliable because it is resistant to atherosclerosis, and its long-term patency rate exceeds 90% after 10 years.
Another useful graft is the radial artery from the forearm. Although its patency is slightly lower than that of the internal mammary artery, it lasts longer than venous grafts. Therefore, many surgeons recommend using arterial grafts, especially in younger patients. However, the final decision depends on the patient’s condition and the surgeon’s judgment — patients should trust their surgeon to choose the best option for them.