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Coronary artery bypass graft (CABG)

Coronary artery bypass graft surgery is a procedure to improve the blood flow to your heart. It’s used to treat coronary heart disease.

Coronary artery bypass graft surgery is also known as CABG, which you may well hear pronounced as ‘cabbage’.

Having a CABG procedure can relieve your angina symptoms, and may also reduce your risk of having a heart attack.

Your heart is supplied with oxygen and nutrients by blood vessels called your coronary arteries. If you have coronary heart disease, these arteries are narrowed or blocked. This can starve your heart of oxygen, which causes angina (the feeling of chest pain, chest tightness and breathlessness). In coronary artery bypass graft (CABG) surgery, your surgeon takes a blood vessel (called a graft) from your chest, leg or arm. They use it to bypass the narrowed or blocked coronary artery. Blood then flows safely through the bypass to reach your heart muscle.

Having a CABG procedure can relieve your angina symptoms, and may also reduce your risk of having a heart attack.

CABG will help to manage your symptoms but it won't cure coronary heart disease, so it's possible that you might get more blockages. Making some healthy lifestyle changes will help reduce the chance of this happening.

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Coronary artery bypass graft (CABG) surgery
How the operation is carried out

Details

  • Preparation Preparing for a coronary artery bypass graft

    Your surgeon will explain how to prepare for your coronary artery bypass graft (CABG) operation. For example, if you smoke, you’ll be asked to stop. Smoking increases your risk of getting a chest and wound infection, which can slow your recovery. You may also be asked to temporarily stop any medicines you normally take before your procedure.

    Having a CABG procedure usually means a hospital stay of about seven days. It’s done under general anaesthesia which means that you’ll be asleep during the operation.

    You’ll be asked to follow fasting instructions as you’ll be having a general anaesthetic. This means not eating or drinking, typically for about six hours beforehand. However, it's important to follow your surgeon or anaesthetist's advice.

    You may be asked to wear compression stockings to help prevent blood clots forming in the veins in your legs. You may need to have an injection of an anticlotting medicine called heparin as well as, or instead of, wearing compression stockings.

    Your surgeon will discuss with you what will happen before, during and after your procedure, and any pain you might have. This is your opportunity to ask questions so that you understand what will be happening. You don’t have to go ahead with the procedure if you decide you don’t want it. Once you understand the procedure and if you agree to have it, you’ll be asked to sign a consent form.

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  • Alternatives What are the alternatives to coronary artery bypass graft?

    There are several alternatives to having coronary artery bypass grafting. These include the following.

    • Medicines, including calcium channel blockers and/or beta-blockers, may improve your symptoms or prevent your condition from getting worse.
    • A coronary angioplasty is a procedure in which your surgeon (usually a cardiologist) opens up your coronary artery from inside, using a special balloon. The balloon is inserted in a plastic tube called a catheter, into a blood vessel in your groin or wrist, up into your coronary artery. Often a stent (a small metal tube) is used to help keep the artery open. When the coronary artery is opened up like this the blood can flow more easily to your heart muscle.

    The treatment you’re offered will depend on the how severe your symptoms are, the condition of your coronary arteries and how healthy you are generally. Your surgeon will discuss with you which treatment is most suitable for you.

  • The procedure What happens during coronary artery bypass graft?

    Your coronary artery bypass graft (CABG) procedure may take between three and six hours. You’ll have a general anaesthetic, which means you’ll be asleep during your operation.

    Your surgeon will take an artery or vein from your leg, arm or chest to use as a graft. If your surgeon needs to bypass more than one coronary artery, they’ll probably use both an artery and a vein. Removing these blood vessels doesn’t affect the circulation in the parts they’re removed from.

    To reach your heart, your surgeon will make a cut down the middle of your breastbone (sternum) and will open your chest. They will then attach the grafts in the correct places to bypass the narrowed parts of your coronary arteries. You may just have one graft, or there may be several.

    Your surgeon may temporarily stop your heart and divert your blood to a heart-lung (bypass) machine while they attach the new grafts. This helps to maintain oxygen levels in your blood during the operation. Or your surgeon may attach the new grafts while your heart is still beating. This type of surgery is called off-pump or beating heart CABG. See our frequently asked questions for more information.

    After attaching the grafts, your surgeon will restart your heart (if it was stopped in the operation). They will then rejoin your breastbone using stainless steel wires which will stay inside your body permanently. Your surgeon will close the skin on your chest with staples or stitches.

    Keyhole surgery

    CABG can sometimes be done using keyhole surgery. This is minimally invasive surgery – also called mini heart bypass surgery. The main difference between keyhole surgery and the traditional CABG procedure is that your breastbone doesn’t need to be cut.

    There are several different kinds of keyhole surgery for coronary artery bypass grafting. Your surgeon will make two or three small cuts in your chest and will pass special instruments through the cuts to perform the operation. Your surgeon may use remote-controlled surgical instruments (known as robot-assisted surgery).

    Keyhole surgery for CABG is still being tested by surgeons and isn't yet widely used. It isn’t suitable for everybody – your surgeon will advise you if it's appropriate for you. If you do have keyhole surgery, there's a chance your surgeon may need to convert to open surgery if it's impossible to complete the operation safely using the keyhole technique.

  • Aftercare What to expect afterwards

    Intensive care

    After your coronary artery bypass graft (CABG) operation, you’ll be taken to the intensive care unit (ICU). Here you’ll be closely monitored until you wake up and your condition is stable. Then you’ll usually be moved to a ward which can provide specialist care for patients after heart operations. Altogether, you’ll probably be in hospital for about five to seven days.

    While in hospital, you’ll be connected to machines that record the activity of your heart, lungs and other body systems. These might include a ventilator machine to help you breathe.

    You’ll be offered pain relief to help with any discomfort as the anaesthetic wears off.

    You’ll probably have an intravenous (IV) tube placed into your vein to give you fluids and medicines. You may have a catheter to drain urine from your bladder into a collection bag. You may also have tubes running out from the chest wound. These drain fluid into another bag and are usually removed after a day or two.

    You may be wearing compression stockings on your legs to help maintain circulation. You’ll be encouraged to get out of bed and move around as this will help prevent chest infections and blood clots developing in your legs.

    Physiotherapy and rehabilitation

    While you’re in hospital, you’ll usually be visited by a physiotherapist (a health professional who specialises in maintaining and improving movement and mobility). They will guide you through exercises designed to help your recovery. You may also meet someone from cardiac rehabilitation. Cardiac rehabilitation is a programme of exercise and information which helps you get back up on your feet after a heart operation or a heart attack. It’s something you can plan to do in your recovery time after you get home.

    Going home

    When you're ready to go home, you’ll need to arrange for someone to drive you home. Try to have a friend or relative stay with you for the first week or so.

    Your nurse will give you some advice about caring for your healing wounds before you go home. You may be given a date for a follow-up appointment.

    If your breastbone was cut, the wires put in place to hold it together again are permanent. The length of time the dissolvable stitches in your skin take to disappear depends on what type you have. For this procedure, they should usually dissolve in about six to eight weeks. If your stitches are not dissolvable, they can be removed after eight to 10 days.

  • Recovery Recovering from coronary artery bypass graft

    It usually takes about two to three months to make a full recovery from a coronary artery bypass graft (CABG) procedure. This varies between individuals so it’s important to follow your surgeon’s advice.

    If you need pain relief, you can take over-the-counter painkillers such as paracetamol or ibuprofen. Always read the patient information leaflet that comes with your medicine and if you have any questions, ask your pharmacist for advice.

    Don't lift heavy objects or do any strenuous activity until your breastbone has fully healed. This may take up to three months. Your surgeon will give you advice about how soon you can return to work and how to exercise safely.

    Follow your surgeon's advice about driving. You mustn’t drive for at least a month and after this time you must be sure that you could safely perform an emergency stop. If you drive a lorry or a bus, you need to notify the DVLA about your operation. You won’t be allowed to drive a lorry or bus for three months. You’ll need to take an exercise test before you’re allowed to drive again. It’s best to contact your motor insurer too so that you’re aware of their recommendations.

  • Risks What are the risks?

    As with every procedure, there are some risks associated with coronary artery bypass grafting (CABG). How these risks apply to you will be different from how they apply to others. Be sure to ask for more information if you have any concerns.

    Side-effects

    These are the unwanted but mostly temporary effects you may get after having the procedure. Side-effects of CABG include:

    • discomfort and perhaps itching from your healing wounds
    • some swelling around the area where your graft was taken from, for example your leg
    • tiredness, and mood swings – feeling upset and emotional
    • loss of appetite
    • muscle pains in your shoulders or upper back
    • constipation
    • scarring – you’ll have permanent scars, which will be pink and noticeable at first, but usually fade over time

    Many of the side effects of CABG go away within four to six weeks after surgery.

    Complications

    Complications are when problems occur during or after the procedure. The possible complications of any operation include infection, excessive bleeding or developing a blood clot, usually in a vein in the leg (deep vein thrombosis, DVT). Specific complications of CABG can include:

    Most people who have CABG won’t get these complications. Your risk tends to be greater if you have the surgery as an emergency or if you have other diseases or conditions. The potential complications of CABG can be serious. But it’s important to remember that you’d also be at risk of some of these complications, like heart attack, if you didn’t have the procedure. Your doctor can help you weigh up the benefits and risks before you decide whether or not to have the procedure.

  • FAQ: What can I do to prevent my arteries narrowing further without surgery? FAQ: What can I do to prevent my arteries narrowing further without surgery?

    Answer

    If you have coronary heart disease, you can help prevent your arteries narrowing further by making lifestyle changes and taking medicines. That way, you may not need surgery such as coronary artery bypass grafting (CABG).

    Explanation

    If you have coronary heart disease, you won’t be able to reverse the damage that’s already been done. But there’s a lot you can do to help yourself, including making some healthy lifestyle changes and taking medicines recommended by your GP.

    Lifestyle changes which may help to prevent your condition from getting worse include:

    • giving up smoking – this is the single most important thing you can do to help your heart
    • maintaining a healthy weight
    • eating a balanced diet
    • staying active
    • keeping your alcohol intake down

    Your GP may recommend that you take medicines to control your blood pressure and cholesterol. If your coronary arteries are narrowed, taking these medicines will help prevent your condition becoming worse. If you have angina, you may be able to manage your symptoms with medicines.

    Ask your doctor for more advice on how to make changes to keep your heart healthy.

  • FAQ: My doctor says that I may be able to have off-pump coronary artery bypass graft. What is this? FAQ: My doctor says that I may be able to have off-pump coronary artery bypass graft. What is this?

    Answer

    Off-pump coronary artery bypass grafting (OPCAB) is an alternative technique to conventional CABG. The difference is that you don’t have to be connected to a heart–lung (bypass) machine with OPCAB.

    Explanation

    In a conventional CABG operation, your surgeon connects your large blood vessels to a bypass machine then stops your heart with medicines. The bypass machine (which is a bit like a pump) then takes over the job of adding oxygen to your blood and maintaining your circulation.

    Off-pump CABG is an alternative technique where your heart continues to beat as your surgeon performs the bypass grafts. It’s also sometimes called ‘beating heart bypass grafting’.

    Doctors were hoping that as OPCAB doesn’t stop the heart, it might have fewer complications. However, so far the evidence seems to show that this isn’t the case. Operating on the beating heart doesn’t seem to be any better than operating with a heart–lung bypass machine. In fact, in the long run, people may do better with the conventional CABG operation using a bypass machine.

    There are some people who may, because of their individual circumstances, benefit from beating heart surgery. Ask your surgeon about what might be best for you.

  • FAQ: Since my coronary artery bypass graft, I’ve been feeling depressed. Is this normal? FAQ: Since my coronary artery bypass graft, I’ve been feeling depressed. Is this normal?

    Answer

    Yes. Feeling depressed, unhappy or anxious is often a natural reaction to having major surgery like CABG.

    Explanation

    After your surgery, you may find that you feel depressed or unhappy. You may well find that your mood swings and you have good days and bad days. Don’t worry; this is normal and something that happens to many people after heart surgery. It will get better.

    Being home alone for long periods of time can make you feel isolated and anxious. It's a good idea to have someone stay with you for the first week or two to keep you company and to take care of you. If you live alone, it should be possible to arrange care visits from a nurse. If you have a job, getting back to work as soon as you are able to will help you avoid depression and isolation.

    When you leave hospital, you’ll usually be asked to book a follow-up appointment with your GP. Your GP can help to provide you with any care that you may need.

  • Resources Resources

    Further information

    Sources

    • Kumar P, Clark M. Clinical medicine. 8th ed. Edinburgh: Saunders; 2012
    • Coronary artery bypass grafting. Medscape. www.emedicine.medscape.com, published 4 April 2014
    • Coronary artery bypass grafting. PatientPlus. patient.co.uk/patientplus.asp, published 9 April 2013
    • Management of stable angina. National Institute for Health and Care Excellence (NICE), July 2011. www.nice.org.uk
    • Map of Medicine. Stable angina. International View. London: Map of Medicine; 2013 (Issue1)
    • Coronary bypass surgery. British Heart Foundation. www.bhf.org.uk, accessed 10 March 2015
    • Angina. British Heart Foundation. www.bhf.org.uk, published 8 April 2014
    • Cardiac rehabilitation. British Heart Foundation. www.bhf.org.uk, accessed 10 March 2015
    • CABG information. The Society of Thoracic Surgeons. www.sts.org, accessed 10 March 2015
    • What to expect after heart surgery. The Society of Thoracic Surgeons. www.sts.org, accessed 10 March 2015
    • Coronary artery bypass grafting. National Heart, Lung, and Blood Institute. www.nhlbi.nih.gov, published 23 February 2012
    • CABG information. Society for Cardiothoracic Surgery in Great Britain & Ireland. www.scts.org, accessed 10 March 2015
    • What to expect after heart surgery. Society for Cardiothoracic Surgery in Great Britain & Ireland. www.scts.org, accessed 10 March 2015
    • Personal communication, Mr Mark Yeatman, consultant cardiac surgeon, 24 April 2015
    • Get well soon. Helping you to make a speedy recovery after surgery to bypass a damaged blood vessel that supplies blood to the heart. The Royal College of Surgeons of England. www.rcseng.ac.uk, accessed 10 March 2015
    • Current medical guidelines: DVLA guidance for professionals. Driver and Vehicle Licensing Agency. www.gov.uk, published 28 November 2014
    • Common postoperative complications. PatientPlus. patient.co.uk/patientplus.asp, published 11 February 2013
    • Møller CH, Penninga L, Wetterslev J, et al. Off-pump versus on-pump coronary artery bypass grafting for ischaemic heart disease. Cochrane Database of Systematic Reviews 2012, Issue 3. doi:10.1002/14651858.CD007224.pub2
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