Surgical Procedure and Actions Inside the Operating Room:
After the patient is transferred to the operating room and placed on the surgical table, the anesthesia team usually arrives at the bedside. Electrodes are attached to the patient’s chest for continuous heart rate monitoring. An intravenous (IV) line is then inserted into a superficial vein of the upper limb using an angiocatheter, through which anesthetic drugs and required fluids are administered.
This is typically the only step during which the patient feels mild pain; after that, there is generally no discomfort. The next step is inserting an arterial line to continuously monitor blood pressure, performed under local anesthesia. Following this, a special mask is placed over the patient’s nose and mouth to deliver oxygen and then inhaled anesthetic gases. Meanwhile, the anesthesiologist administers specific medications to induce full anesthesia and painlessness.
Once anesthesia is achieved, the surgical team begins preparing the necessary vascular grafts, followed by the main stage of surgery — connecting the vascular grafts. In the common and conventional method of coronary artery bypass surgery, a cardiopulmonary bypass machine (heart-lung machine) is used. This device temporarily takes over the function of the heart and lungs, allowing the surgeon to stop the heart and sew the grafts under optimal conditions.
Another method involves performing the bypass without the heart-lung machine, known as off-pump coronary bypass. In this technique, the heart continues beating while the surgeon uses special instruments to attach the grafts.
The number of grafts required for each patient depends on the extent of coronary artery disease, angiography findings, and intraoperative observations. The operation usually takes about 3 to 4 hours. After surgery, patients are transferred to the Intensive Care Unit (ICU).
Almost all patients who undergo coronary bypass surgery are transferred to the ICU while still under partial anesthesia and mechanical ventilation. During this period, they are unconscious and unable to communicate. When the effects of anesthesia wear off and the patient wakes up, they cannot speak due to the breathing tube (endotracheal tube) placed in the trachea for artificial respiration — this is normal and not a cause for concern.
Patients should remain calm and breathe steadily; once their breathing pattern becomes stable, they will be weaned off the ventilator, and the tube will be removed within minutes.
Upon awakening, many patients may feel the urge to urinate, which is usually due to the urinary catheter (Foley) — there’s no need for concern. In the ICU, various monitoring devices are connected to every patient, not because of a severe condition, but for standard postoperative monitoring. Patients also have multiple IV lines for fluids, medications, and sometimes blood transfusions, usually inserted into veins in both arms or the neck.
Another common concern is the presence of chest tubes draining blood from the surgical site. After open-heart surgery, several hundred milliliters of blood loss is normal, and these tubes prevent fluid accumulation inside the chest cavity. Mild discomfort or pain at the insertion site is normal and should not cause anxiety.
Awareness of these points before surgery helps patients remain calm during recovery and facilitates nursing care.
After removal of the breathing tube, patients can breathe easily and speak. They are given water, tea, or juice, and by the next morning can usually eat breakfast. In the first days after surgery, patients are encouraged to take deep breaths and cough to reopen small lung areas that collapsed during anesthesia. They are also given a simple breathing device (spirometer) to help with this exercise.
This is very important because it prevents postoperative lung infections and improves oxygen exchange. If coughing causes pain at the surgical site, patients should press a hand gently over their chest and inform the nurse for pain management.
During ICU stay, before the patient is allowed to walk, they should regularly move their legs or flex calf and thigh muscles to prevent deep vein thrombosis (DVT) — a dangerous blood clot in the legs.
After about 2 days in the ICU, and if no complications arise, patients are transferred to the regular ward. Chest tubes, central venous catheters (C.V.P.), and arterial lines are usually removed at this time.
Around 3–5% of patients may experience significant bleeding or blood clots around the heart that require a return to the operating room within the first 6 hours after surgery. This is not considered a major complication and is often necessary to ensure stable circulation.
Minor postoperative bleeding is common and may result from both surgical site leakage and temporary coagulation disorders caused by the heart-lung machine. Continued use of medications such as Aspirin or Plavix (Clopidogrel) before surgery can also increase bleeding risk.
Postoperative Care in the Surgical Ward:
Patients who have had an uncomplicated ICU recovery no longer need intravenous medications, except possibly for Heparin injections, depending on their condition. Chest tubes, if still present, are removed within 1–2 days.
During surgery, a temporary pacemaker wire is placed on the heart to support heart rhythm if needed. This wire is usually removed painlessly 4–5 days after surgery.
The surgical wound, typically located along the midline of the chest, usually requires no dressing after the third postoperative day.
An echocardiogram is performed around day 4 or 5 to assess heart function, valve condition, and check for fluid or clots around the heart.
Once all tubes and catheters are removed and the patient feels well, they may take a shower, resume light daily activities, and walk several times a day. Rehabilitation staff guide patients in light exercises and short walks.
After 3–5 days in the ward, if no complications are detected, the patient is discharged.
Post-Discharge Instructions:
Patients should:
Take prescribed cardiac medications, especially Aspirin, regularly.
Follow a low-fat, low-salt diet.
Gradually resume daily activities and light walking.
Avoid polluted or smoky environments.
Return for a follow-up visit in 3–4 weeks to evaluate recovery.
If any of the following occur before the scheduled visit, the patient should contact their doctor immediately:
Fever, fatigue, or weakness
Unusual or severe chest pain
Swelling or pain in the legs
Shortness of breath
Redness or discharge from the surgical wound
Common Questions about Coronary Artery Disease:
Q: In coronary bypass surgery, are the coronary arteries removed and replaced?
A: No. The blocked or narrowed part of the coronary artery is bypassed, not removed. A graft is connected from the aorta (or one of its branches) to the healthy section of the coronary artery beyond the blockage.
Q: What are the advantages of endoscopic saphenous vein harvesting?
A: This modern method removes the leg vein through small incisions using an endoscope, avoiding large skin cuts. It improves cosmetic results, reduces pain, and lowers infection risk — though it requires special equipment and experienced surgeons.
Q: Is it better to use arterial or venous grafts for bypass surgery?
A: Arterial grafts are generally more durable and compatible with coronary arteries. The internal mammary artery is the best option, remaining open in over 90% of patients even after 10 years. The radial artery (from the arm) is another good choice, often used in younger patients.
Final graft selection, however, should be determined by the surgeon based on individual conditions — patients should trust their surgeon’s expertise.