What is coronary artery bypass graft (CABG) surgery?

Coronary artery bypass graft surgery is a surgery in which one or more blocked coronary arteries are bypassed by a blood vessel graft to restore normal blood flow to the heart.   These grafts usually come from the patient's own arteries and veins located in the chest, leg, or arm.   The graft goes around the clogged artery to create new pathways for oxygen-rich blood to flow to the heart.

The goals of the bypass surgery are:

1. To relieve symptoms of coronary artery disease (including angina)
2. Enable the patient to resume a normal lifestyle
3. Lower the risk of a heart attack or other heart problems.

Who is a candidate for coronary artery bypass graft surgery?

The decision to prescribe medical treatment, percutaneous intervential procedures or cardiac bypass surgery depends on several factors including the extent of cardiovascular disease, the severity of symptoms, your age and other medical conditions.   The cardiologist (heart specialist) and surgeon will determine the best method of therapy for each patient.

What can I expect?

The surgery generally lasts from three to five hours, depending on the number of arteries being bypassed.

Surgical Procedure

During traditional CABG surgery, a surgeon makes an incision down the center of the chest, cuts through the sternum (breastbone), and retracts the ribcage to get direct access to the heart.   During surgery, the heart-lung bypass machine (called "on-pump" surgery) is used to take over for the heart and lungs during surgery, allowing the circulation of blood throughout the rest of the body.   The heart's beating is stopped so the surgeon can perform the bypass procedure on a "still" heart.

• Traditional Coronary ArteryBypassGraft (CABG) Surgery

During traditional CABG, a surgeon will make an incision down the center of your sternum (breastbone), to get direct access to your heart.   You are connected to the heart-lung bypass machine which allows the circulation of blood and oxygen throughout the body during surgery.   The heart is stopped and the surgeon then performs the bypass procedure.  After surgery, the surgeon closes the breastbone with special wires and the chest with special internal or traditional external stitches.

• Minimally Invasive Coronary Artery Bypass (MIDCAB) Surgery

Your surgeon will review your diagnostic tests prior to your surgery to see if you are a candidate for minimally invasive bypass surgery.

Minimally invasive bypass surgery can be performed through a small thoracotomy (chest wall) incision for patients that require a LIMA (left internal mammary) graft to the LAD.

The benefits to minimally invasive bypass surgery include:

• smaller incision - smaller scar
• shorter hospital stay - in some cases, only 3 days are needed (instead of the average 5 - 6 days for traditional surgery)

Other benefits may include:

• shorter recovery time
• less bleeding
• less potential for infection
• less pain and trauma

Off-Pump or “Beating Heart” BypassSurgery

Off-pump or “beating heart” bypass surgery allows surgeons to perform surgery on the heart while it is still beating.  The heart-lung machine is not used.  The surgeon uses advanced operating equipment to stabilize (hold) portions of the heart and bypass the blocked artery in a highly controlled operative environment.  Meanwhile, the rest of the heart keeps pumping and circulating blood to the body.

Bypass Grafts

There are several types of bypass grafts that can be used.  These types of blood vessels can be used because there are other pathways that take blood to and from the tissues of your chest, arms, and legs.  The surgeon decides which graft(s) to use depending on the location of blockage, the amount of blockage, and the size of your coronary arteries.

• Internal mammary arteries (also called thoracic arteries, IMA grafts)
  The most common bypass grafts used, as they have been shown to have the best long-term results.  In most cases, these arteries can be kept intact at their origin, and then sewn to the coronary artery below the site of blockage because they have their own oxygen-rich blood supply.  If the surgeon removes the mammary artery from its origin, it is then called a "free" mammary artery.  Over the last decade, more than 90% of all patients received at least one internal artery graft.

Surgeons use arteries more than veins to bypass narrowed coronary arteries.  This is done because the arteries do not close nearly as quickly after surgery as do the veins, which have traditionally been used to bypass arteries of the heart.

Radial artery
The radial artery is the second most common type of arterial graft.  There are two arteries in the arm, the ulnar and radial arteries.  Most people receive blood to their arm from the ulnar artery and will not have any side effects if the radial artery is used.  Careful preoperative and intraoperative tests determine if the radial artery can be used.  If you have certain conditions (such as Raynaud's, carpal tunnel syndrome or painful fingers in cold air) you may not be a candidate for this type of bypass graft.  The radial artery incision is in your forearm, about 2 inches from your elbow and ending about 1 inch from your wrist.  After this type of bypass, patients are routinely placed on a medication called a "calcium channel blocker" for about 6 months after surgery to help keep the radial artery widely open.

The gastroepiploic artery to the stomach and the inferior epigastric artery to the abdominal wall are less commonly used for grafting.

• Saphenous veins
  These veins are removed from your leg, and then sewn from your aorta to the coronary artery below the site of blockage. 

To bypass the coronary blockage, the surgeon makes a small opening just below the blockage in the diseased coronary artery.  The graft is sewn into the opening, redirecting the blood flow around this blockage.  If a saphenous (leg) vein or radial (arm) artery are used, one end is connected to the coronary artery and the other to the aorta.  If a mammary artery is used, one end is connected to the coronary artery while the other remains attached to the aorta.  The procedure is repeated until all affected coronary arteries are treated.  It is common for three or four coronary arteries to be bypassed during surgery.

After Surgery

If the procedure was done "on pump," electric shocks start the heart pumping again after the grafts have been completed.  The heart-lung machine is turned off and the blood slowly returns to normal.  Pacing wires and a chest tube to drain fluid are placed before the sternum is closed surgically with special sternal wires and the chest with special internal or traditional external stitches.  Sometimes a temporary pacemaker is attached to the pacing wires to regulate the heart rhythm until your condition improves.

The patient is transferred to an intensive care unit for close monitoring for about one to two days after the surgery.  The monitoring during recovery includes frequent checks of vital signs and other parameters, such as heart sounds and blood work.

Once the patient is transferred to the nursing unit, the hospital stay is about 3 to 5 more days.

What can I expect after my heart surgery?

After successful heart surgery, patients can expect to return to their preoperative condition or better.

When you leave the hospital after heart surgery, you will be given instructions on how to care for yourself during the first phase of recovery which lasts about six to eight weeks.  Those who have had minimally invasive surgery may have a shorter recovery time.

Typical instructions include:

Care of your incision

You will be told how to care for your incision(s) before you leave the hospital.  It is important to:

• Keep your incision(s) clean and dry.
• Use only soap and water to cleanse the area.  Place soapy water on your hand or washcloth and gently wash the incision up and down.  Until the scabs are gone and the skin is completely healed, do not rub the incision with a washcloth.  When showers and baths are permitted, they should be limited to 10 minutes.  The water temperature should be warm - not too hot or cold.  Extreme water temperatures can cause faintness
• Do not apply ointments, oils, salves or dressings to your incision unless specifically told to do so.
• Eat a healthy diet to help healing.

Call your doctor if signs of infection appear:

• Increased drainage or oozing from incision Increased opening of the incision line
• Redness or warmth around the incision
• Increased opening of the incision line
• Increased body temperature (greater than 101 degrees Fahrenheit or 38 degrees Celsius)

Relief of pain

Some muscle or incision discomfort, itching, tightness and/or numbness along your incision are normal after surgery.  You should not have pain in your chest similar to what you had before surgery.  You will be given a prescription for a pain medication before you leave the hospital.

If you had bypass surgery, you may have more pain in your legs than around your chest incision if saphenous vein grafts were used.  Walking, daily activities, and time will help to lessen leg discomfort and stiffness.

Call your doctor if your sternum feels like it moves, or it pops or cracks with movement.

Swelling - for those with vein grafts taken from their legs

You may return home with some swelling in your legs and feet, especially if you had vein graphs taken from your legs.  If you notice swelling:

Place your feet up higher than your heart level when resting.  One way to do this is to lie on your bed or couch and put several pillows under your legs.  Or, you may lie on the floor and place your feet on the couch.  Try this three times a day for one hour to relieve swelling.  (Note- recliners do not adequately elevate your feet).

• Do not cross your legs
• Walk daily even if your legs are swollen
• Hospital support hose may be suggested

Call your doctor if swelling in your leg(s) become worse or painful and/or associated with increased fatigue and/or shortness of breath.

Driving

Your doctor will tell you when you may resume driving.  This usually occurs about six to eight weeks after surgery, however, time may be shorter if you had minimally invasive surgery.  During this time, you may be a passenger as often as you like.

Activity

For the first six to eight weeks:

• Gradually increase your activity.  You may do light household chores, but do not stand in one place longer than 15 minutes.
• Do not lift objects greater than 20 pounds (your doctor may give you a different number if appropriate).  Also, do not push or pull heavy objects.
• It is OK to perform activities above shoulder level, such as reaching for an object or brushing your hair.  But, do not hold your arms above shoulder level for a longer period of time.
• You may climb steps unless they have been restricted by your doctor.  You may need to rest part of the way if you become tired.  Do not climb up and down stairs several times during the day, especially when you first arrive home.  It is better to plan activities to go downstairs in the morning and back upstairs when it is time for bed.
• Pace yourself - spread your activities throughout the day.  If you become tired, rest and schedule unfinished activities for another time.
• Walk daily.  Your doctor or cardiac rehabilitation specialist will give you guidelines for walking when you return home.
• Check with your doctor to confirm activity guidelines.

Medications

You may need medications after surgery.  Your doctor will tell you if you need these medications until you recover from heart surgery or lifelong.  Make sure you understand the names of your medications, what they are for, and what times to take them.  Only take the medications that are prescribed when you are discharged from the hospital.  If you want to take medications you were previously on for other conditions, discuss this with your doctor first.

Diet

You should eat a healthy diet to help you heal.  Your doctor will tell you if you should follow any special diet instructions.  It is common after surgery to have a poor appetite at first.  If this is the case, try to eat smaller, more frequent meals.  Your appetite should return within the first few weeks.  If it does not, contact your doctor.

Sleep

It is important to get enough rest or you may feel overtired and irritable.  Unfortunately, many people complain of having trouble sleeping for some time after surgery.  Normal sleep patterns should return within a few months.  Call your doctor if lack of sleep begins causing changes in behavior or if normal sleep patterns do not return.

Work

You will need to take time to recover, usually about six to eight weeks (may be earlier with minimally invasive surgery).  Your doctor will tell you when you can return to work.  If you have the flexibility at your job, ease back to your work schedule.  If possible, start back at half-time and gradually increase back to your normal routine.

Emotions

It is common after surgery to feel sad or blue.  These feelings should go away after the first few weeks.  If they do not, call your doctor.

Sex

Many patients and their partners feel nervous about resuming sexual activity after heart surgery.  The amount of energy it requires to perform intercourse with a spouse or regular partner is similar to climbing about one or two flights of stairs or walking about one half mile (0.8 km) at a brisk pace.  If you cannot perform these activities without becoming tired or short of breath, please allow additional recovery time before resuming sexual activity.  For the first six to eight weeks, use positions which limit pressure or weight on the breastbone or tension on the arms and chest.

• Keep in mind that a sexual relationship has both physical and emotional aspects
• Talk openly with your partner
• Allow a gradual return of sexual activity
• Have sex when you are rested and physically comfortable
• Create realistic performance expectations - it may take time to return to an active sex life
• Be caring honest and loving with each other

Soon you and your partner will return to a satisfying emotional and physical relationship.  Anxiety on the part of either partner, as well as some medications, may interfere with sexual arousal or performance.  So, discuss any difficulties with your doctor.

Mental Functioning and Heart Surgery

Some people become frustrated during recovery from heart surgery because they feel they are not as sharp mentally as they were before surgery.  These cognitive changes are normal after heart surgery.  The entire body, including the brain, was seriously stressed during surgery, especially if the surgery involved stopping the heart and circulating the blood through a heart-lung machine.  With time, in most cases, normal cognitive functioning returns.  Patience is needed to avoid the frustration that can accompany this side effect of surgery.  You should not force yourself to work or perform mentally stressful tasks, such as balancing a checkbook in the first couple of weeks after surgery.

What is Mended Hearts?

Mended Hearts is a national volunteer support group for heart patients and their loved ones.  If you would like to speak to someone who as been through heart surgery, contact Mended Hearts:

• Nationally:  www.mendedhearts.org or call the American Heart Association Information Line 1-800-AHAUSA1, and ask for Mended Hearts
• Locally:  www.mendedhearts138.org or call 216-791-7500 or write Mended Hearts, Inc, Greater Cleveland Chapter 138, P.O. Box 606133, Cleveland, Ohio  44106

What is cardiac rehabilitation ?

For many people with coronary artery disease, a cardiac rehabilitation program provides an excellent opportunity to begin an exercise program, learn about your heart disease, and learn strategies to change your lifestyle to prevent further progression of your disease.  Your family doctor can give you information about the MetroHealth Cardiac Rehabilitation Program or programs in your local area.  Cardiac rehabilitation is covered by most insurance companies.  Click here to learn more about cardiac rehabilitation.

Recovery

Full recovery from coronary artery bypass graft surgery takes two to three months.  Most patients are able to drive in about six to eight weeks after surgery.  Sexual activity can be resumed in three to four weeks, depending on your rate of recovery.  Most people with sedentary jobs can go back to work in four to six weeks after surgery; people with more physical jobs (such as construction workers or jobs requiring heavy lifting) may have to wait up to twelve weeks before returning to work.  Your doctor will provide specific guidelines for your recovery and return to work, including specific instructions on how to care for your incision and general health after the surgery.

Coronary artery bypass graft surgery does not prevent coronary artery disease from recurring, therefore lifestyle changes and prescribed medications, are strongly recommended to reduce this risk.  Lifestyle changes include quitting smoking, exercising regularly, managing weight, treating high cholesterol, controlling diabetes and high blood pressure, making dietary changes, taking prescribed medications and following up with your doctor for regular visits.