Coronary artery bypass, which creates new routes for blood to ?ow around or bypass a clogged artery, is a major surgical procedure to restore adequate blood supply to the heart. To perform a bypass, a sur- geon removes part of a vein from the person’s leg or thigh, or an artery from the chest wall or arm, and grafts the segment to a blocked coro- nary artery to form a detour around the blockage. You may sometimes hear the operation called CABG (coronary artery bypass grafting, or “cabbage”) or CAB (coronary artery bypass). Doctors may recommend bypass surgery as an aggressive strategy to treat coronary artery disease for a variety of reasons: when medications and lifestyle changes are not enough to prevent severe angina or heart attack, when blockages are numerous and extensive, or when a medical condition such as diabetes or heart failure make other treatments such as angioplasty less work- able. (See “Considering Your Options,” ).
In the United States, more than 500,000 people had bypass surgery in a recent year. Bypass surgery requires dividing the sternum (breastbone) in order to expose the heart. The operation usually  requires putting the person on a heart-lung machine throughout the procedure, meaning that the person’s heart is stopped and not moving while the surgeon works on it.
A person may require more than one bypass to provide adequate blood to the heart. The number of arteries bypassed is not totally indicative of how severe your condition is, however. The location and extent of the blockages are signi?cant as well.

What to Expect

Most coronary artery bypass operations are sched- uled surgeries, rather than being done as an emer- gency measure. If your cardiologist recommends a coronary artery bypass, you will have the opportu- nity to discuss why he or she wants you to have the surgery, what the risks are, what your alternatives
are, and what your family needs to know about your surgery and recov- ery period. If you decide to proceed with the surgery, be sure to remind your doctor about any medications you are taking, including over-the- counter drugs and supplements. Make a list of your medications and bring it with you to the hospital when the surgery is scheduled. As the day of the surgery approaches, tell your doctor about any changes in your health. It is especially important to be aware of symptoms of a cold or ?u, such as fever, chills, coughing, or a runny nose. Even minor infections could affect your recovery.
You will probably be admitted to the hospital the morning of the sur- gery, or perhaps the night before. You will be asked to bathe before arriving. You will be asked not to eat or drink anything after midnight before the surgery, to prevent regurgitating the stomach contents and choking on them. (If you do have something to eat, be honest and tell the doctor or nurse about it.) Be sure to ask whether you should take medications at home—with a very small sip of water—that you nor- mally take each morning. You can expect to have an electrocardiogram (ECG), blood tests, urine tests, and a chest X-ray. Then a nurse will give you a sedative to relax you before you go to the operating room. The areas that will be operated on (your chest and leg or arm) will be washed, sterilized, and shaved if necessary.

How Bypass Is Done

In the operating room you will be wired to an ECG machine to moni- tor your heart . You will be given a local anesthetic before an intravenous (IV) line is placed in your arm, and then you will be given a general anesthetic. The surgery will probably take 4 to 6 hours, depending on the number and complexity of the blockages. When you are completely asleep, a breathing tube (endotracheal tube) will be inserted through your mouth and down your trachea to help you breathe and to enable nurses to clear secretions from your lungs. Another tube will be inserted through your nose and down your throat to your stomach to prevent liquid or air from entering your stomach, so that you will not feel nauseous or bloated after you wake up. A catheter (a thin tube) will be placed in your urethra (the passageway to your bladder) to collect urine during and after the procedure.
You will be given an anticoagulant medication  such as heparin to keep your blood from clotting. Then you will be connected to the heart-lung machine, which will take over your heart’s pumping action and oxygenate your blood during the surgery, so that your heart is still and not full of blood while the surgeons work.
The number of vessels bypassed during surgery depends on how many coronary arteries and their main branches are blocked. Your sur- geon can construct a bypass in different ways. He or she may remove a piece of a long vein in your leg (the saphenous vein) or the radial artery in your arm, neither of which is crucial to the circulation in those areas. The surgeon will stitch one end of the vessel onto your aorta (the large artery leaving your heart) close to where the coronary arteries originate, and graft the other end to the affected coronary artery below the blocked area. In effect, a new artery has been created to route blood around the blockage.
In many cases, at least one bypass will be created using a segment of one or both of the two internal mammary arteries, located behind your breastbone on your chest wall. These arteries originate from the aorta, so the surgeon does not have to entirely remove a piece of the artery. He or she can detach one end of the artery from the chest wall and reat- tach it to the coronary artery below the blockage. Remaining arteries are able to supply the chest wall with adequate blood. These arteries are used frequently because they may have less of a tendency to develop blockages after the surgery.

When the operation is complete, the surgeon makes sure that your heart is adequately supplied, that blood is not leaking, and that the area is soft to the touch. Also, an angiogram while you are still on the table veri?es that your arteries are not leaking internally. Then the surgeon restarts your heart with an electrical shock. The heart function is trans- ferred from the heart-lung machine back to your heart.

Recovery in the Hospital

After surgery you will probably spend the ?rst 1 to 3 days in the inten- sive care unit, where the staff will monitor your heart function closely. You will have a breathing tube and be connected to a ventilator for at least several hours, and you will have temporary drainage tubes in your chest to remove excess blood and ?uids. (Some people, especially those with underlying lung disease, will need to be connected to a ventilator for a longer period of time.) You will have a catheter in your neck or under your clavicle in the chest to permit monitoring of your heart function and pressure. You will also have pacemaker wires attached to the heart muscle that come out of the chest and are attached to a pace- maker generator. You will receive intravenous fluids to keep you hydrated, and you will be given pain medications.

Some hospitals offer pain pumps that allow you to control the deliv- ery of pain medications into your vein. A small catheter is placed in your chest incision that can deliver a local anesthetic directly to the area of your surgery. You can activate the pump by pushing a button at your bedside. Studies show that when patients control their own pain med- ication, the pain is better controlled but also people tend to use less medication. Self-administered pain relief allows people to recover faster and more comfortably.
The breathing tube is removed within hours. Most patients can get out of bed within 24 hours of bypass surgery and can walk in 1 or 2 days. When your doctor is satis?ed that your heart has stabilized, you will be able to leave the intensive care unit, and the other catheters and tubes may be removed. Some people experience a rapid, irregular heart rhythm after the surgery, but this condition can be treated with medica- tions. Or there may be slowing of the heart and if necessary, a pace- maker is installed. You will probably be strong enough to leave the hospital in 5 to 7 days.
Complications of bypass surgery may include pneumonia, urinary tract infection, or stroke. Anemia is common after the surgery, but the body usually recovers over time. Heart rhythm disturbances may occur and require treatment with medication or the installation of a pacemaker.

Recovery at Home

Subsequent recovery at home generally takes several weeks until you get back to your usual self. Some people experience loss of appetite and constipation. You may feel easily tired, moody, or depressed, and it may be dif?cult to sleep. Some people experience swelling in the area from which a blood vessel was removed, such as the lower leg, and you may have some muscle pain in your shoulders and upper back. These effects are normal and will probably disappear in 4 to 6 weeks. A full recovery may take several months, in part because your breastbone must heal, which may be painful. Don’t hesitate to tell you doctor about bother- some side effects.
Your doctor can help you determine how quickly to get back to your daily routines. He or she will probably recommend that you gradually work your way back to normal activities such as walking, going out with friends, doing light housework or yard work, and climbing stairs.

Results of Bypass Surgery

A coronary artery bypass operation improves symptoms such as angina for most people (about 90 percent), and it may prolong life in certain high-risk cases. Most people can return to work or to the same activi- ties they enjoyed before surgery and remain free of symptoms for many years. But bypass surgery does not cure coronary artery disease. New blockages can form in different places in the arteries, and the grafted routes can become clogged. Some branches of arteries are too small to be corrected by a bypass, and blockages in these small arteries can cause angina. Statistically, about 40 percent of people who have bypasses show signs of a new blockage in the bypass grafts within 10 years of surgery.
Controlling the risk factors that lead to blockage is the most impor- tant way that you and your doctor can manage your coronary artery dis- ease. It is more important than ever to maintain normal weight or lose weight if necessary, quit smoking, eat a heart-healthy diet, and get reg- ular exercise. Your doctor will work with you to achieve good control of high cholesterol, high blood pressure, and diabetes. Your cardiologist will want to see you every 1 to 3 months at ?rst, and then at least annu- ally to monitor your condition.
You will almost certainly be advised to take aspirin inde?nitely. Your doctor may also prescribe medications such as ACE inhibitors, beta- blockers, or cholesterol-lowering drugs to help control your disease and improve your heart function.

Cardiac Rehabilitation

A cardiac rehabilitation program, often available through a community hospital, is a medically supervised program to help you learn to live with heart disease. This program provides you with the resources to get any kind of help you need to ease your transition back to a full, sat- isfying life. It involves a commitment of time, but it probably speeds your way to a full recovery. The trained staff can work with you to tai- lor your steps toward recovery to suit you, your medical condition, and your work and family demands. Exercise in a supervised setting, with skilled medical personnel available, usually provides a level of security that helps many people achieve exercise targets more easily and sooner than they would on their own. Many insurance plans cover cardiac rehabilitation. Your cardiologist can give you information about pro- grams near you.
A rehabilitation program usually lasts for the ?rst 3 months or so after your heart attack. It is generally organized in four phases: hospi- talization; early recovery (2 to 12 weeks after you go home); late recovery (6 to 12 weeks or more); and maintenance. The maintenance “phase” extends for the rest of your life, as your lifestyle changes become permanent and you resume your normal activities.
A cardiac rehabilitation program will help you:
• Gradually adjust your level of physical activity to strengthen your heart, monitoring your progress so that you can safely maximize your capacity for exercise
• Adjust your cooking, snacking, and eating styles to focus on a low- fat, low-cholesterol diet
• Work out a plan to balance your diet and exercise needs to control your weight
• Get counseling or other help to quit smoking
• Get advice about the impact of your job on your heart, and how you can take steps to protect yourself
• Learn about techniques (such as yoga, meditation, or massage) to manage stress on and off the job
• Deal with the emotional and psychological sides of the changes in your life
• Talk to other people who are facing the same challenges and mak- ing the same kind of changes in their lives