Surgery Overview
During a
coronary artery bypass, the diseased sections of your coronary arteries are
bypassed with healthy artery or vein grafts to increase blood flow to the heart
muscle tissue. This procedure is also called coronary artery bypass grafting (CABG). Bypass typically requires open-chest surgery.
There are
several newer, less invasive techniques for bypass surgery that can be used
instead of open-chest surgery in some cases. In some procedures, the heart is
slowed with medicine but is still beating during the procedure. For these types
of surgery, a heart-lung bypass machine is not needed. (For open-chest surgery,
a heart-lung machine is needed to circulate the blood and to add oxygen to it.)
Other techniques use keyhole procedures or
minimally invasive procedures instead of open-chest
surgery. Keyhole procedures use several smaller openings in the chest and may
or may not require a heart-lung machine. These techniques are still being
studied and may not be available in all medical centers.
The
material in this section will focus on traditional open-chest bypass surgery.
View the slideshow on CABG surgery to see what happens during a
bypass.
You'll receive
anesthesia before the surgery that will make you
sleep. In most cases, bypass surgery is open-chest surgery. During the surgery,
your chest will be open and your heart exposed. The surgeon makes a large cut,
or incision, in the middle or side of your chest. He or she may cut through your breastbone and
spread apart your rib cage.
The surgeon removes a healthy blood
vessel—often from the leg—and attaches (grafts) it to the blocked artery. The
new blood vessel bypasses the blocked artery to increase blood flow to the
heart. You may need just one bypass graft, or you may need more. Some people
have as many as two, three, or even four (double, triple, or quadruple bypass
surgery). How many grafts you need depends on how many arteries are blocked and
where.
When the surgery is complete, the doctor may use wire to
put your rib cage back together and stitches to close the incision. The surgery
can take 3 to 6 hours. You will stay in the hospital at least 3 to 8 days after
the surgery. It can take 4 to 6 weeks to recover at home. Most people are able
to return to work within 1 to 2 months after surgery.
What To Expect After Surgery
After surgery, there will be a short
stay (1 to 2 days if there are no complications) in the intensive care unit
(ICU). In the ICU, the person will likely have:
- Continuous monitoring of his or her heart
activity.
- A tube to temporarily help with breathing.
- A
stomach tube, to remove stomach secretions until the person starts eating
again.
- A tube (catheter) to drain the bladder and measure urine
output.
- Tubes connected to veins in the arms (intravenous, or IV,
lines) through which fluids, nutrition, and medicine can be
given.
- An arterial line to measure blood
pressure.
- Chest tubes, to drain the chest cavity of fluid and blood
(which is temporary and normal) after surgery.
You will typically stay in the hospital from 3 to 8 days
after open-chest bypass surgery. The amount of time you stay varies and will
depend on your health before bypass surgery and whether complications develop
from surgery.
After discharge, recovery at home takes 4 to 6
weeks. Recovery includes physical therapy, respiratory therapy, occupational
therapy, and diet counseling. Exercise and driving may be resumed after about 2
to 3 weeks. People who are able to return to work can usually do so within 1 to
2 months, depending on the type of work they do. Some people find that they
experience heightened emotions (such as a greater tendency to cry or otherwise
show emotion in ways that are unusual compared with before the procedure) for
up to a year following surgery.
Cardiac rehabilitation
After your surgery, your doctor may suggest that you attend a
cardiac rehabilitation program. In cardiac rehab, a
team of health professionals provides education and support to help you
recover.
The rehab team can help you make new, healthy habits,
such as eating right and getting more exercise.
Why It Is Done
Not
everyone with coronary artery disease needs bypass surgery. Some people can be
helped by
angioplasty with stents. Others use medical therapy,
which involves making lifestyle changes and taking medicines. Some people use
both of those treatments. Your doctor is likely to recommend bypass surgery
only if you will benefit from it and if those benefits are greater than the
risks.
Your doctor may advise bypass surgery if:
- Your left main heart artery is very
narrow.
- All three arteries of the heart are blocked or the amount
of blood flowing through them is very low.
- Your doctor thinks that
bypass surgery will be more successful than angioplasty with stents.
- You also need surgery to repair or replace a heart valve damaged
by
heart valve disease.
- You have
diabetes and two or more blocked
arteries.
- Your heart is having trouble pumping. This is called a
decreased
ejection fraction.
Your choice may depend on the number of arteries that are blocked or which arteries are blocked. Talk with your doctor
about the best treatment for you. The best treatment for you may also depend on your age, your health, and
how much your angina is affecting your quality of life.
To help you make a decision, see the topic:
Heart Disease: Should I Have Bypass Surgery?
How Well It Works
- Bypass surgery reduces angina symptoms. About 95 out of 100 people who have the
surgery get relief from angina right away, while 5 out of 100 do
not.1
- More than 80 people out of 100 are
still free of angina 5 years after surgery.1
- Bypass surgery might increase
your chances of living a longer life. More than 90 people out of 100 who have a
bypass are still alive 5 years after surgery.1
- How long a bypass lasts depends on how long the blood vessel
grafts stay open. The risk of needing another operation gets higher each year after your surgery. After 5 years, about 2 out of 100 people need another surgery. After 10 years, 7 out of 100 people need another surgery.2
Lifestyle changes and medicines
The success of bypass surgery also depends on you.
If you smoke and don't quit, you won't get the most benefit from bypass
surgery. You may need to make some other big changes, like eating right and
getting regular exercise. These changes will help your bypass grafts last and
stay open longer. They will also give you the best chance of living a longer,
healthier life.
If you are taking medicines for angina, to lower
cholesterol, or to control blood pressure, be sure to take these
every day. Along with lifestyle changes, these medicines can help you get the
most benefit from bypass surgery.
Bypass surgery is not a cure
for heart disease. That's why all of these things—eating right, not smoking,
getting exercise, and taking medicines—are so important. Without them, you
raise your risk of getting new blockages and needing another surgery.
Risks
Bypass
surgery has been done for more than 40 years. In the United States, it is one of the most common major surgeries. But it has some serious risks.
The risks of bypass surgery include:
- Death. Out of 100
people who have bypass surgery, 1 to 4 of them will have a serious complication that
leads to death, and 96 to 99 of them will not.2
- Heart attack. Out of 100 people who have
bypass surgery, about 1 will have a heart attack soon after the surgery, and 99 will not.3
- Stroke. Out of 100 people
who have the surgery, 1 to 3 will have a stroke, and 97 to 99 of them will
not.4, 5
- Too much bleeding. This can lead to the need for a transfusion. This happens in
3 to 5 out of 100 people who have the surgery. This means
that 95 to 97 out of 100 people don't have bleeding problems.4
Other risks include return of angina, problems from
anesthesia, and infections at the site of the chest incision. Some people also
have memory loss and trouble thinking clearly. These problems are most common
in older people and tend to improve several months after surgery.
The chances of having a serious problem with bypass surgery are higher if
you are older than 70. Your risk is also higher if you have other problems such
as diabetes, kidney disease, lung disease, or
peripheral arterial disease. Talk
with your doctor to find out how your health affects your risk.
What To Think About
When bypass surgery is clearly
needed, surgery improves symptoms and in some cases prolongs life. But in
many situations, the reasons for doing bypass surgery instead of other
treatments are less clear.
In each case, the cardiac surgeon or cardiologist should
be able to clearly explain why bypass surgery is preferred over medicine or
angioplasty. Sometimes, a second opinion can be helpful when it is not clear
that surgery needs to be done.
Transmyocardial laser revascularization (TMR) is sometimes used
along with bypass surgery. TMR uses a laser beam to improve blood flow
to the heart and relieve angina. It is not common but may be done to reach areas of the heart
where bypass grafting does not work as well. And it is not the right treatment for everyone.
Complete the surgery information form (PDF)(What is a PDF document?) to help you prepare for this surgery.
References
Citations
- Bravata DM, et al. (2007). Systematic review: The
comparative effectiveness of percutaneous coronary interventions and coronary
artery bypass graft surgery. Annals of Internal Medicine, 147(10): 703–716.
- Sabik JF, et al. (2011). Coronary bypass surgery. In V Fuster et al., eds., Hurst's The Heart, 13th ed., vol. 2, pp. 1490–1503. New York: McGraw-Hill.
- Gray RJ, Sethna DH (2012). Medical management of the patient undergoing cardiac surgery. In RO Bonow et al., eds., Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine, 9th ed., vol. 2, pp. 1793–1810. Philadelphia: Saunders.
- Morris DC, et al. (2011). Management of the patient after cardiac surgery. In V Fuster et al., eds., Hurst’s The Heart, 13th ed., vol. 2, pp. 1504–1512. New York: McGraw-Hill.
- Tarakji KG, et al. (2011). Temporal onset, risk factors, and outcomes associated with stroke after coronary artery bypass grafting. JAMA, 305(4): 381–390.
Other Works Consulted
- Hillis LD, et al. 2011 ACCF/AHA Guideline for coronary artery bypass graft surgery: A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation, 124(23): e652–e735.
Credits
| By |
Healthwise Staff |
| Primary Medical Reviewer |
E. Gregory Thompson, MD - Internal Medicine |
| Primary Medical Reviewer |
Rakesh K. Pai, MD, FACC - Cardiology, Electrophysiology |
| Specialist Medical Reviewer |
John A. McPherson, MD, FACC, FSCAI - Cardiology |
| Specialist Medical Reviewer |
Robert A. Kloner, MD, PhD - Cardiology |
| Last Revised |
May 15, 2012 |
Bravata DM, et al. (2007). Systematic review: The
comparative effectiveness of percutaneous coronary interventions and coronary
artery bypass graft surgery. Annals of Internal Medicine, 147(10): 703–716.
Sabik JF, et al. (2011). Coronary bypass surgery. In V Fuster et al., eds., Hurst's The Heart, 13th ed., vol. 2, pp. 1490–1503. New York: McGraw-Hill.
Gray RJ, Sethna DH (2012). Medical management of the patient undergoing cardiac surgery. In RO Bonow et al., eds., Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine, 9th ed., vol. 2, pp. 1793–1810. Philadelphia: Saunders.
Morris DC, et al. (2011). Management of the patient after cardiac surgery. In V Fuster et al., eds., Hurst’s The Heart, 13th ed., vol. 2, pp. 1504–1512. New York: McGraw-Hill.
Tarakji KG, et al. (2011). Temporal onset, risk factors, and outcomes associated with stroke after coronary artery bypass grafting. JAMA, 305(4): 381–390.
