Coronary Artery Bypass Surgery (CABG): What to Expect

From the authors of The Cardiac Surgery Playbook: Daniel T. Engelman, MD, Cheryl Crisafi, MSN, RN, and Armando Paez, MD

Coronary artery bypass grafting, usually called CABG or bypass surgery, is the most common heart operation in the United States. If your cardiologist or surgeon has recommended it, you probably have many questions. This guide explains what the operation does, how it is done, and what the weeks afterward usually look like.

Why bypass surgery is done

The coronary arteries carry blood to the heart muscle itself. Over years, fatty deposits called plaque can narrow or block them. When the heart muscle does not get enough blood, you may feel chest pressure with effort, called angina. A sudden blockage causes a heart attack.

Bypass surgery does not remove the blockages. Instead, the surgeon attaches a healthy blood vessel so blood can flow around each blockage. The new route is called a graft. One graft is a single bypass. Three grafts is a triple bypass. The number tells you how many blockages were bypassed, not how serious your condition is.

Bypass or stents?

Many blockages can be opened with a stent, a small mesh tube placed through a catheter. Surgery is generally favored when several arteries are blocked, when the main left coronary artery is narrowed, when the heart muscle has weakened, or when you have diabetes along with multiple blockages. In these situations bypass surgery has been shown to give longer-lasting relief and better long-term results for many people. For patients at very high surgical risk, stents or other treatment may be the better choice. The heart team decides together with the patient.

At most hospitals a heart team, made up of cardiologists and surgeons, reviews your pictures together and recommends one approach. It is fair to ask why they chose it for you. Our page on questions to ask your heart surgeon can help you prepare for that conversation.

Where the grafts come from

The grafts are your own blood vessels. Your body has spares, so taking them does not harm the areas they came from. Surgeons choose from a few sources:

• The internal mammary artery, which runs along the inside of the chest wall. It is the preferred graft for the most important artery on the front of the heart, because these grafts stay open the longest, often for decades.
• The saphenous vein from the leg. It is usually removed through one or more small incisions with a camera, so the leg heals faster than it did with the long cuts used years ago.
• The radial artery from the forearm, used in some patients after a simple test confirms the hand has good blood flow from its other artery.

How the operation is done

Most bypass operations are done through an incision down the middle of the chest, with the breastbone divided. This gives the surgeon a clear view of the whole heart. The operation often takes three to five hours, longer if more grafts are needed. You are fully asleep under general anesthesia the entire time.

In most cases the heart is stopped and a heart-lung machine takes over while the surgeon sews the grafts, which are only a few millimeters wide. Some surgeons do the operation on a beating heart, called off-pump bypass. A smaller number of patients are candidates for a minimally invasive or robotic approach through a smaller incision between the ribs. Your surgeon will explain which approach fits your anatomy. Our page on the day of surgery and the ICU walks through what happens hour by hour.

The hospital stay and the first weeks at home

Most people spend a day or so in intensive care and go home about four to seven days after surgery. You will be up walking within a day. If a vein was taken from your leg, expect some swelling and numbness around the incision. Raising the leg when you sit and wearing a compression stocking, if your team recommends one, both help.

The breastbone takes about six to eight weeks to knit together. During that time you will follow sternal precautions, such as keeping your elbows close to your body and not lifting heavy objects. Driving usually waits about four to six weeks. Timelines differ from program to program, so follow the instructions your own team gives you. Minimally invasive approaches can shorten some of these times. Some programs are also moving toward fewer sternal precautions and earlier driving. Only your own surgeon can tell you whether that applies to you. Let pain be your guide. If an activity hurts your chest, stop and give the bone time to heal. Our pages on recovery after open heart surgery and recovery week by week give more detail.

Life after bypass: protecting the result

Bypass surgery relieves symptoms and can lengthen life, but it does not cure coronary artery disease. The same process that blocked your arteries can affect the grafts and the rest of your arteries over time. What you do after surgery matters as much as the operation.

Nearly everyone goes home on aspirin and a statin to protect the grafts, and often a beta blocker and a blood pressure medicine. Take them as prescribed and do not stop any of them without asking. Join cardiac rehab, which is one of the strongest steps you can take. Quit tobacco for good, work toward a heart-healthy eating pattern, and keep your blood pressure, cholesterol, and blood sugar at the targets your team sets.

Learn more in The Cardiac Surgery Playbook

The Cardiac Surgery Playbook explains bypass surgery in far more depth in Chapter 3: Coronary Bypass Surgery (CABG), including how the grafts work, how surgeons and cardiologists decide between stents and surgery, and diagrams of the heart's arteries. Chapter 24: Protecting Your Heart for Life covers the medicines and habits that keep the grafts open.

Go deeper in the book. Chapter 3: Coronary Bypass Surgery (CABG); Chapter 24: Protecting Your Heart for Life. Written by a cardiac surgeon, a cardiac surgery nurse and an infectious disease physician, with worksheets you can fill in for your own care.

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This page is general education, not medical advice. Your own surgeon and care team know your situation best. If you think you are having a medical emergency, call 911.

More questions before heart surgery