A flagship intervention in cardiac surgery, coronary bypass surgery consists of creating, using transplanted veins, a “bridge” in order to bypass the blocked part of an artery, and thus restore satisfactory blood flow to the heart. During a triple bypass, three bypasses of this type are made to bypass three obstructions.

As a reminder, the coronary arteries are the two arteries that bring oxygenated blood to the heart. In the case of atherosclerosis, an atherosclerotic plaque (deposit of fat and fibers) forms inside the artery and ends up narrowing its caliber, reducing blood flow and therefore oxygenation of the heart. This is called coronary insufficiency or coronary disease. This problem can lead to angina pectoris (or angina) or even, when the artery is completely blocked, a heart attack (MI or myocardial infarction).

To restore the blood flow necessary for the proper functioning of the heart muscle, it is possible to resort to coronary artery bypass grafting. This surgical intervention consists of “bypassing” one or more blocked coronary arteries by grafting blood vessels. Depending on the number of strictures, one or more bypass grafts can be performed during the same operation; in this case, three for a triple bypass.

To create this bypass, an artery or vein from the patient (autograft) is used: the internal mammary arteries (branches of the thoracic aorta) or the internal saphenous veins (superficial veins of the leg).

Before the operation

Before the operation, a complete assessment is carried out with chest x-rays, blood tests, electrocardiogram (ECG) and coronary angiogram (x-ray with a contrast product to make the arteries visible) to precisely define the location and the degrees of obstruction of the arteries.

The operation

The operation takes place under general anesthesia and lasts several hours.

The surgeon begins by performing a median sternotomy, he will open the thorax by cutting the sternal bone. He then takes the mammary veins or saphenous veins, after making a small incisition in the leg for them. 

Once the veins are removed, an extracorporeal circulation (ECC) is set up using a specific machine. The CPB allows to temporarily replace the function of pump of the heart and the function of oxygenation of the lungs to be able to work on a stationary heart and without blood flow.

The surgeon then proceeds to bypass. A small incision is made on the aorta downstream of the narrowed or obstructed area, the vein or artery removed is implanted between the aorta and the affected coronary artery. Sutures are made with extremely fine polypropylene thread. For a triple bypass, the surgeon performs this procedure in three different places.

When bypass surgery is complete, the heart and lungs are put back into operation and the extracorporeal circulation (ECC) is interrupted. Chest drains are placed to evacuate fluids, the breastbone is closed and the skin sutured.

Atherosclerosis, that is to say the progressive obstruction of the coronary arteries, can lead to angina pectoris or angina. This is manifested by a deep pain located in the middle of the thorax, with a feeling of intense tightness, distressing. This bar pain occurs on exertion (fast walking, uphill, against the wind) and requires stopping. Myocardial infarction is the major complication of angina pectoris.

To prevent or treat (if they have occurred) these two pathologies, it is necessary to restore good blood circulation to properly revascularize the heart muscle. Different solutions exist: 

• drug treatment;
• angioplasty: a small balloon is inserted into the artery to dilate it;
• coronary bypass surgery, when these two solutions have not worked or are not suitable for the patient. This is particularly the case when several coronary arteries are blocked, as is the case with a triple bypass.

Operative suites

The patient remains 24 to 72 hours in intensive care for close monitoring 24 hours a day by a nurse and a resuscitator. The first hours, breathing is assisted by an intubation probe inserted into the mouth. Once the catheter is removed, the patient can breathe on their own, with an oxygen mask. Respiratory aerosols and physiotherapy are performed to help the patient breathe well. Chest drains are removed after 24 hours.

Getting up is usually done two days after the operation. The patient is then transferred to the surgical department, where he is hospitalized for 10 to 15 days depending on his condition. There, he gradually resumes a normal diet and continues aerosols and respiratory physiotherapy.

Then comes a period of rehabilitation in a rehabilitation center or on an outpatient basis.

At the end of the rehabilitation, a visit to the cardiologist makes it possible to take stock. This assessment may include a stress test and possibly a coronary angiography to check the patency of the bypass grafts and the quality of the revascularization.

The results

A commonly practiced and very well-mastered procedure, coronary bypass surgery, whether single, double or triple, is one of the most effective operations to resolve the problems of narrowing of the coronary arteries. By removing the obstruction of the blood flow, it improves the blood and oxygen supply to the heart, relieves the chest pain of angina pectoris and reduces the risk of heart attack. Even with advances in coronary dilation techniques, bypass surgery remains the technique with the best results and with the fewest serious side effects.

However, coronary artery bypass surgery does not treat the cause of this obstruction, namely atherosclerosis, which often finds its origin in a poor lifestyle. After the operation, it is therefore essential to adopt a better lifestyle: healthier eating habits, regular physical activity, smoking cessation, weight control, high blood pressure and diabetes.

The patient is regularly monitored by his attending physician and cardiologist, and must take chronic drug treatment: beta blockers, antiplatelet drugs (APAs), statins among others.

The risks

Although very frequently performed, bypass surgery remains a major surgery. In addition to the risks inherent in anesthesia, the risks associated with bypass surgery depend on the patient’s state of health.