Coronary Artery Bypass Graft

1. Preparation

WHAT IS A CORONARY ARTERY BYPASS GRAFT?

A coronary artery bypass graft, commonly known as heart bypass surgery, is a procedure that restores the flow of blood to the heart by taking a healthy artery or vein from either the leg, arm or chest and transferring it to the outside of the heart. This bypasses one or more of the arteries that are narrowed or blocked due to coronary artery disease.

Coronary artery disease is a condition caused when a buildup of plaque, consisting of fatty deposits, cholesterol and calcium, stick to the walls of the arteries. This causes narrowing and blockages of the heart arteries, reducing the blood flow to the heart. This in turn may cause clots that can result in a heart attack. The main risks factors for coronary artery disease are:

A diet that includes a large amount of saturated fats
Obesity
Smoking
Inactivity
Unstable diabetes
High blood pressure
High cholesterol
A family history of heart disease

WHY IS IT DONE?

The risk of having a heart attack is lessoned considerably by restoring the blood flow to the heart. It may also reduce the risk of arrhythmias (irregular heart rhythms), and heart failure. Coronary Artery Bypass Surgery is increasingly performed only in patients for whom stenting (a minimally invasive procedure involving the insertion of a small tube to relieve coronary artery blockage) is inappropriate or has already failed.

HOW DO I CHOOSE A SPECIALIST?

Your GP or cardiologist will be able to recommend and refer you to a cardiothoracic surgeon. You may be happy to accept their advice and recommendation, or you may like to investigate your choices; either option is safe and valid.

In Australia each medical speciality has a governing body to which the consultants belong – they are then called ‘fellows’ of the college. These are often good organisations to turn to for information about what you can expect from your medical specialist. You can access the Royal Australasian College of Surgeons via their website at www.surgeons.org. They are responsible (through the Australasian society of cardiac and thoracic surgeons) for training and maintaining educational standards of cardiac surgeons, and their web site allows you to search for fellows in your area.

The list of questions below may help you to better understand your care, and if necessary decide on a particular doctor. Practical issues you may also like to consider are what hospital(s) does a particular doctor operate from, and what are their fees. (If you need more information about fee setting and gap arrangements, please refer to our brochure “what you should know before going into hospital”, which is also available on the HCF website).

To access a list of Cardiac Surgeons who participate in HCF’s Medicover no gap arrangement:

Call HCF Member Services on 13 13 34
Visit one of HCF’s customer service branches
Access HCF’s website at www.hcf.com.au / members / find a health professional / find a doctor

Please note: Participation in HCF’s no gap initiatives is at the doctor’s discretion. HCF does not guarantee that every medical service provided by these doctors will be a no gap service. Some doctors who participate in the HCF Medicover No Gap arrangement have chosen not to be listed on the HCF website. Patients are encouraged to confirm with their doctor whether they will support HCF’s no gap initiatives for their treatment.

In addition to your surgeon, you will also require an assistant and an anaesthetist. Although for logistical reasons you will probably not have a choice in who they are, you should ask your surgeon about their service and fees.

WHAT SHOULD I ASK MY SPECIALIST?

Make sure you fully understand the procedure that is planned; do not be afraid to ask.
It is your right to know all the relevant information, as this is part of informed clinical and financial consent.
In addition to what the procedure involves, you should also ask about:
- Likely outcomes – how will your quality of life improve
- Any side effects or possible complications
- Preparation – including any lifestyle changes you can make to improve your recovery
- What can you expect during your hospital stay
- Follow up appointments - jot down any questions or concerns you may have so that you can ask your doctor at your next appointment
- You should always tell your doctor all medication you are taking (including herbal and homeopathic remedies).

Most medication should be continued as usual, but the following is a list of some that may require special instruction:

Aspirin (or any related products),
Arthritis medication,
Pain medication,
Insulin.

Don't forget to mention any homeopathic or herbal remedies you are taking, as these can have side effects and interactions too.

WHERE IS IT DONE?

Many hospitals now have the facilities to perform coronary artery bypass grafts. Generally though, they will be in one of the major cities, as the hospital has to be large enough to have an Intensive Care Unit and access to a range of medical specialists.

HOW LONG IS THE PROCEDURE?

Although the Coronary artery bypass grafting itself usually takes less than an hour, the time in theatre can vary between 2.5 – 5 hours

WHO IS INVOLVED?

The people involved in the procedure are:

Your Cardiothoracic Surgeon
Assistant surgeon
Anaesthetist: Gives you a general anaesthetic and looks after you before and during the procedure
A perfusionist – a specially trained anaesthetist who operates the heart lung bypass machine
Specialised Nurses for the procedure and recovery
Physiotherapist
Radiologist
Pathologist

HOW DO I PREPARE FOR A CORONARY ARTERY BYPASS GRAFT?

You will usually be required to attend a pre-admission clinic where you will undergo basic tests to assess your general fitness for surgery. These include an ECG (recording of your hearts’ rhythm), chest x-ray and blood tests. Your doctor should advise you of any lifestyle changes – such as giving up smoking or weight loss – that you should undertake before your operation. As with any surgery, part of the preparation is to find out as much information as you need to feel comfortable with what is going to happen to you.

WHAT DO I TAKE WITH ME TO THE HOSPITAL?

Bring any recent, relevant x-rays and scans
Do not bring any valuables with you
It’s best not to take any jewellery into hospital
Bring only enough money for items such as newspapers and magazines
Slippers or flat rubber soled shoes for walking in the hallways
Make sure that you bring any medication that you would usually take during the day, under some circumstances you may still be able to take these
Personal grooming items such as hairbrush, comb, toothbrush, deodorant etc.
Undergarments, sleepwear, and a robe
Comfortable clothes
Remove all nail polish and do not wear any make-up

2. Costs and Charges

WHAT IS IT GOING TO COST?

Ask your doctor whether he will participate in HCF’s no gap arrangement for your surgery so that you do not incur any out of pocket expense. If your doctor does not wish to participate, it is your doctor’s responsibility to fully inform you of your financial liability and any out of pocket expense prior to you consenting to the surgery.

For your information, the average charges for claims paid for Coronary Artery Bypass Graft admissions for the financial year 06/07 are provided below:

	On Average
	Charge	Medicare Pays	HCF Pays	³ If your doctor DOES NOT use HCF’s No Gap Arrangement YOU PAY	% of all admissions where your doctor DOES NOT use HCF’s No Gap Arrangement	⁴ If your doctor USES HCF’s No Gap Arrangement YOU PAY	% of all admissions where your doctor USES HCF’s No Gap Arrangement
Total Average Hospital Component (accommodation, theatre and hospital related services)	$21,078		$20,856
¹ Medical Services Component
Anaesthetic Services	$4,208	$1,843	$614	$1,853	12.5%	$0	87.5%
Assistant in Operations	$698	$349	$116	$455	21.5%	$0	78.5%
Cardio-Thoracic Surgical Services	$4,332	$1,973	$658	$2,255	34.7%	$0	65.3%
Diagnostic Procedures	$131	$81	$27	$48	7.7%	$0	92.3%
Miscellaneous Medical Services	$2,140	$1,259	$420	$1,017	21.3%	$0	78.8%
Pathology Services	$1,077	$706	$235	$210	20.6%	$0	79.4%
Specialist Consultation	$709	$404	$135	$163	24.8%	$0	75.2%
Radiology Services	$960	$551	$184	$200	30.2%	$0	69.8%
² Total Average Medical Services	$13,840	$6,941	$2,314	$2,181	65.9%	$0	34.1%
Hospital and Medical Services Average for Coronary Artery Bypass Graft Admissions	$34,918	$6,941	$23,170	$2,181	65.9%	$0	⁵ 34.1%

Points to Note:

Charges are based on HCF claims for a sample size of 331 overnight admissions with an average length of stay of 11.8 days in private participating hospitals (private hospitals that have an agreement with HCF for accommodation, theatre and hospital related services) – covered under Medicare items 38500 and 38503.
As a private patient in a non-participating hospital you may incur an out of pocket expense for the hospital component (accommodation, theatre and hospital related services).
The average hospital benefit that HCF pays excludes your excess on your product.

¹These medical services are in-patient services only.

²The medical charges are based on averages and each episode of care is different, i.e.

you may not have all of these medical services, and/or you may also have other medical

services not indicated here. Therefore, the total average medical service charge

($13,840) differs from the sum of the individual average charges as shown.

³Doctors who do not use the HCF no-gap arrangement have a higher average out of

pocket charge, as their charges are higher than those doctors who use the no-gap

arrangement and incur nil out of pocket charges to the patient. Therefore, the sum of the

average benefits plus the average out of pocket charge you pay will not equate to the

charge as shown in the table.

⁴Doctors’ charges vary so always ask your doctor whether he/she will participate in

HCF’s No Gap Arrangements.

HCF Medicover Schedule of Benefits lists all services for extra benefit in excess of the

Commonwealth Medicare Benefits Schedule (CMBS) fee, which providers, registered

under the HCF Medicover No Gap arrangement will receive as full payment for

services provided. This also applies to unregistered providers should they charge within

the schedule of benefit listed. This arrangement ensures that our members incur no out of

pocket expense.

⁵This percentage indicates the total coverage of hospital and medical services for all

coronary artery bypass graft admissions. The percentages shown for each type of

medical service are much higher as they are calculated for those services only and not

the entire admission, which includes all medical services and the hospital services. In an

admission you may have one medical service with an out of pocket expense, which then

excludes the whole admission from being fully covered. Hence the significant difference

in percentage for individual types of medical services as compared to the total admission

fully covered.

2. Day of procedure

WHAT HAPPENS TO ME AT THE HOSPITAL?

In most cases you will be admitted to hospital the day before your surgery. When you arrive at the hospital, the receptionist will do all the paperwork necessary for your stay. Please ensure that you let the staff know of any medication you are taking (including homeopathic and herbal remedies) and any allergies that you may have.

Once this admission procedure is completed, you will be taken to the ward, where a nurse will perform a series of basic tests and assessments. You may be started on a blood thinning medication such as heparin to help prevent blood clots during the procedure.

Your anaesthetist will usually see you the evening before surgery. It is the anaesthetist’s job to ensure your safety through the operation, so he/she will examine you and review your test results. They will also explain the anaesthetic to be used, and the pain relief you will be given afterwards. For a coronary artery bypass graft you will be given a general anaesthetic which means you will be fully asleep and feel no pain throughout the procedure.

Some hospitals will offer you and your close relatives the chance to visit the Intensive Care Unit on the day before surgery (this is where you will wake up and spend the first couple of nights after surgery). If you have never visited an Intensive Care, it can look a little daunting at first. Many people find visiting the unit, and perhaps even seeing other people who have just undergone the same or similar procedure, helps to reduce the anxiety they feel when it’s their turn to be either the patient or visitor.

At some stage before your operation, your surgeon will ask you to sign a consent form. He/she is legally obliged to obtain your informed consent – this means that you should understand as much as practically possible about the procedure and any possible complications or side effects. You will obviously have had a discussion with your doctor about this before admission, but it’s never too late to ask questions.

The evening prior to your surgery, you will be asked to shower with an antiseptic soap and the operative area will be shaved. You may also be given a sedative that evening, and will usually have medication to relax you before going to theatre the next day.

You will need to fast so it is important that you follow instructions with regard to your last meal and drink; generally you will have to fast from midnight for a morning operation but may be allowed an early breakfast if you are on the afternoon list.

Your doctor may have his/her own specific preparation requirements. These instructions should be strictly followed.

WHAT HAPPENS DURING A CORONARY ARTERY BYPASS GRAFT OPERATION?

You will probably be given medication before you leave the ward so that you feel slightly drowsy before going to theatre. Once in the anaesthetic room, if you do not already have one inserted, a small plastic needle – a cannula – will be placed into a vein in your hand or arm. This will then be used to give you an intravenous sedative to put you to sleep (the first stage of your anaesthetic). You won’t remember anything more until you wake up in Intensive Care.

Once fully asleep, you will be taken into the operating theatre. The first stage of the operation is to ‘harvest’, or remove, the veins to be used for the bypass.

Once this is done, a cut about 25cm long will be made down the middle of your sternum (breastbone) and the ribcage will be opened to enable the surgeon to reach your heart. The new vein grafts are sometimes attached while the heart is still beating but in most cases your heart is temporarily stopped with medication and the blood is redirected to a heart-lung bypass machine while this is being done.

The heart-lung bypass machine replaces the functions of the heart and lungs by adding oxygen to the blood and maintaining circulation while the grafts are put in place. Once grafting is complete the blood is then directed back to the heart. The heart is restarted with the help of controlled electric shocks.

The sternum is then joined together again using wires and the skin is sutured closed with stitches that gradually dissolve on their own. Plastic tubes are left in place to allow the drainage of any remaining blood from the space around the heart.

3. Aftercare

WHAT HAPPENS AFTER A CORONARY ARTERY BYPASS GRAFT?

After the operation is finished you will be taken straight to the Intensive Care Unit (you do not go to the recovery unit as with smaller operations). It is their job to stabilise you after the procedure: Your breathing tube will remain in place and you are connected to a ventilator, you may receive medication through a drip to help control your blood pressure, your chest drain tubes are connected to very gentle suction to make sure any blood loss is removed from the chest, and of course your heart rate, blood pressure, and oxygen levels (among other things) are closely monitored. Sometimes your surgeon may put in ‘pacing wires’ – small wires that allow temporary connection of an external pacemaker to help control your heart rate if required. Most intensive care units allow close family to visit at this early stage, but it may take an hour or so after you leave the theatre before you can receive visitors.

It will take several hours after the surgery until you begin to wake up, and you will have to keep the breathing tube in your throat until you are fully awake – this time varies considerably between roughly 6 -12 hours. Some people find the breathing tube and ventilator to be an uncomfortable experience; if this applies to you, just remember that this an absolutely crucial part of the process, and the tube will be removed as soon as it is safe to do so. Also, many people look back and find they have little or no memory of this time. Once the breathing tube has been removed, you will have to use oxygen from a mask or nasal prongs for at least a day or so – sometimes for a good deal of your hospital stay.

Your chest tubes will usually be removed the day after the operation, after which you will be able to get out of bed and even start taking small walks with some assistance. Although when you first wake up after cardiac surgery you are attached to lots of drips, monitors and drains, most people are surprised at how quickly these are removed and your recovery begins. You will be encouraged to be as active as possible, and you will be shown breathing exercises to help re-expand your lungs (they were collapsed whilst on the heart-lung bypass machine). It is impossible to over state the importance of early mobilisation and active breathing exercises to your recovery.

In order to control your pain, you will usually be given tablets regularly as well as strong analgesia such as morphine. The way this is delivered depends on the hospital – you may have a pump you are able to control yourself (a PCA, patient controlled analgesia), or the nurses may have to give you an injection either into a vein or muscle. Although it’s impractical to promise that you will have no pain at all after such big surgery, everyone will do their best to make you as comfortable as possible. It’s very important that you communicate honestly about your pain and need for pain control, because the more comfortable you are, the more you will be able to move.

You will be able to start drinking and perhaps eating very lightly the day after your operation, and then build back up to your normal diet gradually. Your intravenous drip is likely to remain in place for several days, and longer if you need any medication such as antibiotics. Your urinary catheter is usually removed after a couple of days.

The normal Intensive Care stay is 2 nights, after which you will be transferred to the cardiac ward. You may stay on a cardiac monitor and you will certainly continue to have your blood pressure and other observations checked frequently. You will usually be able to get in the shower quite quickly, usually within a few days of the operation, depending on whether all your drips and drains have been removed and how well your wounds are healing. The sternal (chest) wound is normally stitched with internal, dissolvable sutures that create a very neat scar – it is usually dry and able to be left without a dressing within a couple of days. You will become more and more independent until your discharge home. Although according to our data the average length of stay after coronary artery bypass grafting is 10 days, the majority of people are discharged after 7 or 8 days.

In some instances you may be offered a cardiac rehabilitation program to guide you through your recovery and assist you to be as healthy as possible in the future.

You should also be given circumstances for which you should seek further medical assistance after discharge. You may find that some of your medication is altered whilst you are in hospital, or in the period after your operation. You will have follow up appointments with your cardiologist to monitor your progress. You will have to modify certain activities for a while, such as heavy lifting – the physiotherapists will go through this with you before discharge. You should also check with your doctor and car insurance company before resuming driving, especially in the first six weeks.

Before you are discharged you will be given instructions regarding:

Care of your wound(s)
Diet and exercise
Any changes to your regular medication
Driving
Symptoms for which you should seek further medical attention