Heart surgery is a broad category of complex medical procedures performed on the heart or the major blood vessels connected to it. These interventions aim to correct a wide array of problems, ranging from congenital defects to damage caused by conditions like coronary artery disease or heart valve dysfunction. Because the heart cannot be stopped without consequence, performing surgery requires specialized techniques and a highly coordinated team of professionals.
Pre-Surgical Assessment and Patient Preparation
The process begins long before the patient arrives in the operating room, focusing on thorough assessment and stabilization. Preoperative evaluation involves a battery of diagnostic tests, including electrocardiograms (ECGs), chest X-rays, and often cardiac catheterization or angiograms. These tests map the heart’s vessels and structure, providing the surgical team with a precise roadmap of the heart’s current condition and the specific issues that need correction.
A multidisciplinary team, including the surgeon, cardiologist, and anesthesiologist, reviews these findings to formulate the surgical strategy. Patients follow strict protocols before the procedure, including using antiseptic scrubs and fasting. Once in the operating suite, monitoring lines are placed to continuously track heart rate, blood pressure, and oxygen saturation.
The final preparatory step is the administration and monitoring of general anesthesia. The anesthesiologist induces controlled unconsciousness and manages ventilation through a breathing tube. They monitor the patient’s physiological responses throughout the operation, using advanced equipment to maintain stable blood pressure and gas exchange. This intensive monitoring ensures the patient is pain-free and stable as the surgical phase begins.
Categorizing Surgical Approaches
Surgeons employ different techniques to gain physical access to the heart, depending on the specific repair needed and the patient’s overall health. These methods dictate the size and location of the incision, which affects the recovery profile and visibility for the surgeon. The primary division is between conventional “open” access, which provides the greatest visibility, and less invasive approaches.
Conventional Cardiac Surgery
The traditional method for accessing the heart is a median sternotomy, the foundation of conventional cardiac surgery. This technique involves making a vertical incision of six to eight inches down the center of the chest. The sternum (breastbone) is then divided lengthwise to allow the ribcage to be spread apart.
This wide access offers the surgeon maximum visibility and space to work on the heart’s chambers, valves, or vessels. Procedures like complex coronary artery bypass grafting (CABG) or extensive valve replacements rely on this exposure. Once the procedure is complete, the sternum is rejoined using specialized stainless steel wires that remain permanently in the chest.
Minimally Invasive Surgery (MIS)
Minimally invasive approaches (MIS) reduce the physical trauma associated with a sternotomy. These techniques utilize smaller incisions, often two to three inches long, made between the ribs or a partial cut through the sternum (mini-sternotomy). Specialized, long-handled instruments and video-assisted technology are inserted through these small openings to perform the repair.
This less disruptive method results in less blood loss, a reduced risk of infection, and a faster recovery time compared to conventional open heart procedures. MIS is often used for single valve repairs, certain bypass procedures, and some congenital heart defect corrections. Robotic-assisted surgery is a refinement of MIS, where the surgeon controls high-definition cameras and wristed instruments from a console, allowing for enhanced dexterity inside the chest.
Catheter-Based Procedures
The least invasive approach involves procedures that do not require a chest incision, instead using vascular access through a major blood vessel. These interventions, such as transcatheter aortic valve replacement (TAVR) or angioplasty, use a catheter inserted through an access point, typically the femoral artery in the groin. The catheter is then guided through the blood vessels to the heart under continuous X-ray imaging.
Once in position, specialized tools on the end of the catheter are deployed to treat the issue, such as inflating a balloon to open a blocked artery or deploying a new heart valve. These procedures are preferred for patients who may be too frail for major surgery, as they bypass the need to stop the heart or open the chest. The access site is small, usually requiring only a puncture or a few sutures for closure.
Mechanics of Cardiopulmonary Bypass
Many complex cardiac operations require the heart to be still and bloodless for intricate repairs, a condition made possible by the cardiopulmonary bypass (CPB) machine. This device, often called the heart-lung machine, temporarily takes over the function of both the heart and the lungs. The CPB circuit is managed by a dedicated specialist known as a perfusionist.
The process begins with the insertion of specialized tubes, or cannulae, into the patient’s large blood vessels (such as the right atrium or vena cava) to drain oxygen-poor blood away from the body. This venous blood flows into a reservoir on the machine, often assisted by gravity or vacuum suction. The machine’s pump then propels the blood through the circuit, mimicking the work of the heart.
The drained blood is directed into an oxygenator, which functions as the patient’s lungs by adding oxygen and removing carbon dioxide. A heat exchanger allows the perfusionist to precisely control the blood’s temperature, often cooling the patient to reduce metabolic demand and protect organs. Once oxygenated and temperature-regulated, the blood is filtered and pumped back into the patient’s systemic circulation, typically through an arterial cannula placed in the aorta.
While the machine circulates the blood, the surgeon administers a potassium-rich solution called cardioplegia to the heart muscle. This solution rapidly stops the heart from beating, creating the motionless, bloodless surgical field necessary for the delicate repair. The CPB machine maintains vital blood flow and oxygenation to the rest of the body, allowing the surgeon the time required to complete the repair on the arrested heart.
Immediate Post-Surgical Procedures
Once the cardiac repair is completed, the surgical team begins restoring the body’s natural circulation. If cardiopulmonary bypass was used, the perfusionist gradually reduces the machine’s support as the heart warms up and the effects of the cardioplegia wear off. The heart usually resumes beating on its own, but sometimes an electrical shock is necessary to restart a normal rhythm.
The patient is “weaned” off the CPB machine, with the surgeon monitoring the heart’s ability to take over the full workload of pumping blood. Once stable, the cannulae connecting the patient to the CPB circuit are removed, and the insertion sites are closed. The surgeon then places temporary drainage tubes into the chest cavity to remove excess fluid or blood that may accumulate following the operation.
The final step involves closing the surgical access site. If a median sternotomy was performed, the breastbone is securely wired together before the muscle and skin layers are closed with sutures or surgical staples. All monitoring lines and temporary tubes are secured, and the patient is transferred directly to the Cardiac Intensive Care Unit (ICU) for continuous post-operative monitoring.