Coronary bypass surgery: when it is needed, what happens and recovery

What is coronary bypass surgery?

In coronary heart disease the arteries supplying the heart become narrowed by fatty plaques. The heart muscle gets less blood, especially during exertion, which causes chest pain (angina), breathlessness and a risk of heart attack.

In CABG the surgeon takes a healthy blood vessel from elsewhere in the body and attaches it so that blood can flow around the narrowing. The most common grafts are:

• the internal mammary (thoracic) artery from inside the chest wall – very durable and usually used for the heart's most important artery;
• the radial artery from the forearm;
• the great saphenous vein from the leg.

One operation can include one, two, three or more grafts, which is why people talk about a "double" or "triple" bypass.

When is bypass preferred over a stent?

Many people with coronary disease are treated with medicines alone or with coronary angioplasty and a stent. Bypass surgery tends to be considered when:

• the left main coronary artery is significantly narrowed;
• all three main arteries are affected (three-vessel disease), particularly if the blockages are complex;
• the patient has diabetes and several diseased arteries;
• the heart's pumping function is reduced;
• stenting is technically difficult, or stents have repeatedly narrowed again;
• another heart operation is needed at the same time, such as surgery on a heart valve.

European guidance (ESC/EACTS) stresses that the decision should be made by a heart team – an interventional cardiologist, a cardiac surgeon and other specialists as needed – taking into account the anatomy, other illnesses and the patient's own preferences. A scoring tool called the SYNTAX score is often used to grade how complex the blockages are.

Tests before the operation

Before planned bypass surgery you can usually expect:

• coronary angiography to map exactly which arteries are narrowed and where;
• an echocardiogram to assess heart muscle and valve function;
• an ECG, blood tests and kidney and liver function checks;
• a Doppler ultrasound of the neck (carotid) arteries and sometimes the leg vessels;
• a chest X-ray and occasionally lung function tests;
• a dental check to rule out hidden infection.

Tell the team about every medicine you take. Some blood thinners need to be paused for a certain number of days before surgery – but only on medical advice.

How the operation is done

CABG is performed under general anaesthetic and usually lasts three to five hours. The standard approach is a median sternotomy – an incision down the breastbone.

On-pump or off-pump

• On-pump surgery – the heart is temporarily stopped while a heart-lung machine takes over pumping and oxygenating the blood. This is the most widely used method.
• Off-pump (beating-heart) surgery – the grafts are stitched in while the heart keeps beating, using special stabilising devices. It suits certain patients in experienced centres.

Minimally invasive options

Some centres offer bypass through a small incision between the ribs (MIDCAB) or with robotic assistance, usually when only one or two arteries need grafting. Not everyone is suitable – it depends on the anatomy and the team's experience.

Risks and possible complications

CABG is major surgery, but in specialist centres the risk of a planned operation is low. It depends on age, heart function, kidney and lung health, diabetes and whether the operation is urgent. Possible complications include:

• atrial fibrillation and other heart rhythm problems – common in the first days and usually temporary;
• bleeding requiring a return to theatre;
• wound infection of the breastbone or leg;
• stroke – uncommon but serious;
• a temporary decline in kidney function;
• problems with memory and concentration in the first weeks, which settle for most people.

Your surgeon will explain your individual risk, often calculated with a standard scoring system such as EuroSCORE II.

Recovery after bypass surgery

Most patients spend one or two days in intensive care and around five to eight days in hospital overall. Recovery then continues at home:

• The breastbone takes about six to eight weeks to heal; avoid heavy lifting and pushing with your arms until then.
• Driving – usually after about four to six weeks, once your doctor agrees.
• Work – often six to eight weeks for desk jobs, longer for physical work.
• Cardiac rehabilitation – strongly recommended; it combines gradual exercise, education and emotional support.

Tiredness, poor sleep and mood swings are common in the early weeks. Daily walks that get gradually longer are the best start – see physical activity and health.

Caring for your wounds at home

Keep the chest and leg wounds clean and dry. A shower is usually allowed a few days after surgery, but baths and swimming should wait until the wounds have fully healed. If a vein was taken from your leg, raising it when you sit helps, because swelling is common for some weeks. Check with your team before starting any new medicine or supplement, as some interact with blood thinners.

Long-term outlook

Bypass surgery does not cure atherosclerosis. It reroutes blood around the narrowings, but the disease can progress elsewhere and in the grafts themselves. The key to a lasting result is:

• taking antiplatelet medicine, a statin and any other prescribed drugs every day;
• stopping smoking completely;
• keeping blood pressure, cholesterol and blood sugar under control;
• heart-healthy eating and maintaining a healthy weight;
• regular cardiology follow-up.

Arterial grafts, particularly the internal mammary artery, stay open for many years in most patients. Vein grafts are more likely to narrow over time.

When to see a doctor, and treatment abroad

See a cardiologist if you get chest pain or breathlessness on exertion, if medicines no longer control your angina, or if bypass surgery has been recommended after angiography and you want to understand your options. After surgery, contact a doctor promptly for fever, redness or discharge from a wound, new palpitations, breathlessness or swelling. For severe chest pain, call 112.

Some patients choose to seek a second opinion or have surgery at large accredited hospital groups in Istanbul. If you are considering this, check the hospital's accreditation and the cardiac surgeon's experience with your specific operation, ask for a written treatment plan and arrange follow-up and rehabilitation at home in advance. New City Clinic is an Istanbul-based organiser that coordinates hospital, doctor, accommodation, transfers and an interpreter; medical decisions remain with the doctors.