CABG: A Protocol

To the well trained eye, it seems primitive and routine. Never mind the fact that the procedure I am alluding to can take 3-4 hours, assuming there are no complications, and requires an advanced team of cardiothoracic surgeons, anesthesiologists, nurses, and perfusionists to complete successfully. Technically speaking, Coronary Artery Bypass Grafting, or "CABG", which is pronounced as the food "cabbage", is an open-heart surgery in which a portion of a blood vessel is grafted from the aorta to the coronary artery in order to bypass the blocked section of the coronary artery and improve the blood supply to the heart. Having had the great honor of performing it on an already deceased pig heart a few times before at Stanford University, I can somewhat vouch for those who acknowledge the fact that this procedure is not merely a cut here, few sutures there, then done. Still, only a qualified MD truly understands what is mentally and physically involved when evaluating a case sitting on the operating room table. Though, to the average patient, “CABG” can simply mean them going under on a metal table and sea of wires, all to hopefully come out with their coronary artery disease under control.

For the calculated surgeon, the logistics of the procedure become routine, but not everything can be written down in a medical textbook. What happens as a side note during surgery does not typically make it in the professional records… 

Coronary Artery Bypass Graft Surgery Protocol According to John Hopkins University (and occasionally, me):

1. You (the patient shaking in your own skin out of nervous anxiety) will be asked to remove any jewelry or other objects that may interfere with the procedure. You will change into a hospital gown and empty your bladder. (Take these few minutes by yourself to calm your nerves and give your twitching knees a break. Breathe.)

2. A healthcare professional will insert an intravenous (IV) line (the kind that everyone seems to have stories about being accidently stabbed by numerous times because of that one nurse who can’t seem to get it right) in your arm or hand. Other catheters will be put in your neck and wrist to monitor your heart and blood pressure, as well as to take blood samples. (They’ll give you a stress ball and tell you to close your eyes, pretending like that helps any). 

3. You will lie on your back on an operating table. (Your eyes will be focused on the cracked ceiling and the baby blue gown your surgeon is wearing.) 

4. The anesthesiologist will continuously monitor your heart rate, blood pressure, breathing, and blood oxygen level during the surgery. (Your surgeons will tell you to count down as you fall asleep- that number will be the last thing you remember for a few hours). Once you are sedated (meaning, put into a deep sleep as if you’re stuck in a blank dream you cannot possibly force yourself to awake from), a breathing tube will be put into your throat and you will be connected to a ventilator, which will breathe for you during the surgery (… little do you know). 

5. A catheter will be put into your bladder to drain urine. (It’s natural, and at the end of the day, they’re saving your life).

6. The skin over the surgical site will be cleaned with an antiseptic solution. (Meanwhile, your surgeons find it to be just another day on the job. The assistant surgeon explains how they have their daughter’s dance recital to attend tonight. A bit of nonchalant hospital gossip is even exchanged.)

7. Once all the tubes and monitors are in place, your doctor will (first, say/do their lucky ritual- as expected before every operation begins-, then) make incisions in one or both of your legs or one of your wrists to access the blood vessel(s) to be used for the grafts. He or she will remove the vessel(s) and close those incision(s). (Casual, right? The best part is, you won’t even feel a thing. By this point you’re in a whole different world. Trust your doctors. They know a thing or two.)

8. The doctor will make an incision (cut) down the center of your chest from just below the Adam's apple to just above the navel. (You will see the scar the next time you stare at yourself through the mirror, but don’t let it just be a scar. Remind yourself of all you’ve been through and how far you’ve come since. You should be proud.) The doctor will cut the sternum (breastbone) in half lengthwise (like they do in television where the camera seems unnecessarily close to the scalpel and the overly dramatic music begins to play.) He or she will separate the halves of the breastbone and spread them apart to expose your heart. (Still, your surgeon is harmlessly chatting with the assistant. Their hands seem to guide themselves at this point- the epitome of acquired instincts if you ask me.)

(Now this is when it gets fun…)

     9. To sew the grafts onto the very small coronary arteries, your doctor will need to stop your heart temporarily. (Mind you, the technique needed to carry this out is extremely tedious and must be, absolutely must be, executed perfectly. No pressure, Dr.) Tubes will be put into the heart so that your blood can be pumped through your body by a heart-lung bypass machine. (Now you can say you’ve lived the life of a robot for a matter of time. Isn’t that quite the story to tell in of itself?)

     10. Once the blood has been diverted into the bypass machine for pumping, your doctor will stop the heart by injecting it with a cold solution. (Brain freezes are overrated anyways.)

     11. When the heart has been stopped, the doctor will do the bypass graft procedure by sewing one end of a section of vein over a tiny opening made in the aorta, and the other end over a tiny opening made in the coronary artery just below the blockage. (Without a doubt, this step is my favorite. Precision and accuracy is key, especially here. The sutures must be flush and flawless in order to work correctly, so you can count on everyone in the OR being completely focused and wired with a different mindset. Silence may even fall over the room. For them, it doesn’t get more peaceful, nor magical than that. Skip straight to step 18 to learn the second half of this favorite.) If your doctor uses the internal mammary artery inside your chest as a bypass graft, the lower end of the artery will be cut from inside the chest and sewn over an opening made in the coronary artery below the blockage. 

     12. You may need more than one bypass graft done, depending on how many blockages you have and where they are located. After all the grafts have been completed, the doctor will closely check them as blood runs through them to make sure they are working. (The doctors’ chit chat will again pause for a bit here. Surgeons are very meticulous, and rightfully so. Any signs of misalignment or abnormal blood flow is not taken lightly.)

     13. Once the bypass grafts have been checked, the doctor will let the blood circulating through the bypass machine back into your heart and he or she will remove the tubes to the machine. Your heart may restart on its own, or a mild electric shock (delivered through metal plates resting against your heart… no biggie…) may be used to restart it.

     14. Your doctor may put temporary wires for pacing into your heart. These wires can be attached to a pacemaker and your heart can be paced, if needed, during the initial recovery period. (Robot X2?)

     15. Once your doctor has opened the chest, he or she will stabilize the area around the artery to be bypassed with a special instrument.

     16. The rest of the heart will continue to function and pump blood through the body.

     17. The heart-lung bypass machine and the person who runs it may be kept on stand-by just in case the procedure need to be completed on bypass. (Keep in mind, this is a team effort. Sure, surgeons have the scalpel, but a given surgery is much more than that. Everyone involved from patient to nurse to family has a pivotal role to play in the success of a procedure.)

     18. The doctor will do the bypass graft procedure by sewing one end of a section of vein over a tiny opening made in the aorta, and the other end over a tiny opening made in the coronary artery just below the blockage. (Remember my note about this step? Now we’ve come full circle. Again, attention to detail and fine motor skills are not taken for granted.)

     19. You may have more than one bypass graft done, depending on how many blockages you have and where they are located. (Piece-of-cake.)

     20. Before the chest is closed, the doctor will closely examine the grafts to make sure they are working. (Reminder, it is more than crucial the doctors be very meticulous at this point. Settling is not an options for a surgeon and their team.)

     21. Your doctor will sew the sternum together with small wires (like those sometimes used to repair a broken bone, though, this time it happens to be your chest)

     22. He or she will insert tubes into your chest to drain blood and other fluids from around the heart. (Assuming the situation is manageable, the pressure weighing over your team’s head will fade a bit. The “typical friends meeting in a coffee shop” vibe will pick up again.)

     23. Your doctor will sew the skin over the sternum back together. (Don’t worry. Your body is strong. It can take it.

     24. Your doctor will put a tube through your mouth or nose into your stomach to drain stomach fluids. (You won’t even feel a thing. This is the home stretch!)

     25. He or she will then apply a sterile bandage or dressing. (Wrap changes will become the usual for a while following the procedure, but nothing you cannot handle.)

     26. (Finally, you will rest in bed and your doctors will deliver the news to your loved ones who have been pacing the hallway for the past 3 ½ hours. Eventually, your eyes will peel open and you’ll find a smiling visitor whispering with their hand pasted on top of yours. Let me ask, do you remember counting?)