New York Health - Should I have coronary artery bypass graft (CABG) surgery?...

Introduction

This information will help you understand your choices, whether you share in the decision-making process or rely on your doctor's recommendation.

Key points in making your decision

Consider the following when making your decision:

Bypass surgery can relieve chest pain (angina) and other symptoms. Most people who have bypass surgery get relief from chest pain right away.
Surgery can improve your chances of living a longer life. It may also reduce your risk of heart attack.
Most of the time, bypass surgery is open-chest surgery. It carries the rare risk of heart attack, stroke, and even death. Your recovery will take 4 to 6 weeks at home.
Bypass surgery can't cure coronary artery disease. You will still need to make changes in the way you eat and how much you exercise. These changes, along with not smoking, will give you the best chance of living a longer, healthier life. And you will probably need to take medicines.
Decisions about whether or not to have surgery will depend on how strong your heart muscle is, how many arteries are blocked, which arteries are blocked, how bad the blockages are, and your overall health.
Bypass surgery is just one treatment for coronary artery disease. Others include angioplasty with stents, medicines, and lifestyle changes. Ask your doctor what you can expect to happen if you have bypass surgery compared with using these other treatments.

Medical Information

What is coronary artery bypass surgery?

Coronary artery bypass graft surgery (also called CABG or "cabbage") helps improve blood flow to the heart in people with severe coronary artery disease. The surgeon connects, or grafts, a healthy artery or vein from another part of your body to the blocked coronary artery. The grafted blood vessel goes around (bypasses) the blocked part of the artery. This provides a new pathway for blood to your heart.

The goals of bypass surgery are to:

Relieve chest pain (angina) and other symptoms of coronary artery disease.
Improve your quality of life.
Increase your heart's ability to pump blood.
Improve your chances of living a longer life.
Reduce your chances of having a heart attack.

Bypass surgery does a good job of treating coronary artery disease, but it is not a cure. Bypass surgery doesn't change the way arteries harden or narrow because of heart disease. And even after surgery, you can still get new blockages. These can occur in the new blood vessels that bypass the blocked arteries, as well as in the original coronary arteries.

What happens during and after bypass surgery?

You'll receive anesthesia before the surgery that will make you sleep. In most cases, bypass surgery is open-chest surgery. During the surgery, your chest will be open and your heart exposed. The surgeon makes a large cut, or incision, in your chest. He or she then cuts through your breastbone and spreads apart your rib cage.

The surgeon removes a healthy blood vessel-often from the leg-and attaches (grafts) it to the blocked artery. The new blood vessel bypasses the blocked artery to increase blood flow to the heart. You may need just one bypass graft, or you may need more. Some people have as many as two, three, or even four (double, triple, or quadruple bypass surgery). How many grafts you need depends on how many arteries are blocked and where.

When the surgery is complete, the doctor will use wire to put your rib cage back together and stitches to close the incision. The surgery can take 3 to 6 hours.

You will stay in the hospital at least 3 to 5 days after the surgery. It can take 4 to 6 weeks to recover at home. Most people are able to return to work within 1 to 2 months after surgery.

See a slideshow on bypass surgery to see how it is done.

How do you know if you need bypass surgery?

Not everyone with coronary artery disease needs bypass surgery. Some people can be helped by angioplasty with stents or medical therapy, which involves making lifestyle changes and taking medicines, or both. Your doctor is likely to recommend bypass surgery only if you will benefit from it and if those benefits are greater than the risks.

Your doctor may advise bypass surgery if:

Your left main heart artery is very narrow.
All three arteries of the heart are blocked or the amount of blood flowing through them is very low.
Your doctor thinks that bypass surgery will be more successful than angioplasty with stents.
You also need surgery to repair or replace a heart valve damaged by heart valve disease.
You have diabetes and two or more blocked arteries.
Your heart is having trouble pumping. This is called a decreased ejection fraction.

If only two of your arteries are blocked and neither of these is the left main artery, your choice may not be as clear. Talk with your doctor about the best treatment for you. This may depend on your age, your health, and how much your chest pain is affecting your quality of life.

What are the risks of bypass surgery?

Bypass surgery has been done for more than 30 years. In the United States, it is done more often than any other major surgery. But it has some serious risks.

The risks of bypass surgery include:

Death. Out of 100 people who have bypass surgery, 2 of them will have a serious complication that leads to death, while 98 of them will not.¹
Heart attack. Out of 100 people who have bypass surgery, 5 will have a heart attack, and 95 will not.²
Stroke. Out of 100 people who have the surgery, 1 to 5 will have a stroke, and 95 to 99 of them will not.³
Too much bleeding, leading to the need for a transfusion. This happens in 30 out of 100 people who have the surgery.⁴ This means that 70 out of 100 people don't have bleeding problems.

Other risks include return of angina, problems tied to anesthesia, and infections at the site of the chest incision.

Some people also have memory loss and trouble thinking clearly. These problems are most common in older people and tend to improve several months after surgery.

The chances of having a serious problem with bypass surgery are higher if you are older than 70. Your risk is also higher if you have other problems such as diabetes, kidney disease, lung disease, or peripheral arterial disease. It's important to talk with your doctor to find out how your health affects your risk.

How well does bypass surgery work?

Bypass surgery reduces angina and other symptoms of coronary artery disease. About 95 out of 100 people who have the surgery get relief from chest pain right away, while 5 out of 100 do not.³

More than 80 people out of 100 are still free of chest pain 5 years after surgery.³ People who have bypass surgery tend to have longer relief from repeat heart problems compared to other treatments.

Bypass surgery can increase your chances of living a longer life. More than 90 people out of 100 who have a bypass are still alive 5 years after surgery.³

How long a bypass lasts depends on how long the blood vessel grafts stay open. Most bypass grafts that are done with arteries stay open for 10 years or more. That makes it less likely that you will need a repeat surgery during that time.⁵

The success of bypass surgery also depends on you. If you smoke and don't quit, you won't get the most benefit from bypass surgery. You may need to make some other big changes, like eating right and getting regular exercise. These changes will help your bypass grafts last and stay open longer. They will also give you the best chance of living a longer, healthier life.

If you are taking medicines for angina, to lower cholesterol, or to control blood pressure, it's also important to take these every day. Along with lifestyle changes, these medicines can help you get the most benefit from bypass surgery.

Bypass surgery is not a cure for heart disease. That's why all of these things-eating right, not smoking, getting exercise, and taking medicines-are so important. Without them, you raise your risk of getting new blockages and needing another surgery.

Are there other treatment choices?

Other choices for you and your doctor to talk about are:

Angioplasty with stents. Angioplasty has fewer risks in some patients, and recovery is quicker than with surgery. But there is a greater chance that the artery will narrow again within 1 year. This means that you may need another angioplasty or bypass surgery to reopen it. For at least a year after angioplasty with stents, you may need to take medicine to reduce the risk of blood clots.
Medicines and lifestyle changes. This is sometimes called medical therapy. This may be a choice for you if your chest pain is not affecting your quality of life. But in order to be successful, you'll need to follow a strict program of medicines and lifestyle changes, including eating right, getting regular exercise, and not smoking.

Bypass surgery offers more relief from chest pain and other symptoms and the chance at a longer life compared with making lifestyle changes and taking medicines alone.⁶

Bypass surgery and angioplasty with stents have similar results in terms of improving your chances of living a longer life.⁷ But bypass surgery will help keep your arteries open longer. It's also a better choice if your coronary arteries are narrow or if the amount of blood flowing through them is very low.

If you have diabetes, bypass surgery is almost always better than angioplasty. Bypass surgery lowers the risk of death and heart attack in people with diabetes compared to angioplasty with stents. Bypass surgery can also help you live longer than angioplasty with stents if you have a decreased ejection fraction.

Ask your doctor what you can expect to happen if you have bypass surgery, compared with having other kinds of treatment like medical therapy or angioplasty with stents. Your doctor should be able to tell you why bypass surgery would be a good choice. Sometimes it helps to see another doctor to get a second opinion.

For more information on angioplasty, see:

Should I have angioplasty?

If you need more information, see the topic Coronary Artery Disease.

Your Information

Your choices are:

Have coronary artery bypass surgery.
Don't have coronary artery bypass surgery. Try other treatments instead, such as angioplasty or medicines and lifestyle changes.

The decision whether to have bypass surgery takes into account your personal feelings and the medical facts.

**Deciding about bypass surgery**
Reasons to have bypass surgery	Reasons to not have bypass surgery
Bypass surgery may reduce the risk of heart attack. Bypass surgery can relieve chest pain (angina) and help you live longer. You have a major blockage in the left main coronary artery, or three of your arteries are blocked. Your blocked arteries can't be treated by angioplasty with stents. People who have bypass surgery tend to have longer relief from repeat heart problems compared to other treatments. You have diabetes, or your heart has trouble pumping (decreased ejection fraction). Are there other reasons you might want to have coronary artery bypass surgery?	Your chest pain (angina) doesn't bother you too much, and you can manage it with medicines. Bypass surgery has rare risks that include death, heart attack, and stroke. Your blocked arteries do not include the left main coronary artery, and you don't have diabetes. You want to try another treatment such as angioplasty with stents. You have only one or two blocked arteries, and the blockages are not too severe. You are committed to making lifestyle changes and want to try medical therapy first. Are there other reasons you might not want to have coronary artery bypass surgery?

These personal stories may help you make your decision.

Wise Health Decision

Use this worksheet to help you make your decision. After completing it, you should have a better idea of how you feel about coronary artery bypass surgery. Discuss the worksheet with your doctor.

Circle the answer that best applies to you.

I will do whatever I can to avoid bypass surgery.	Yes	No	Unsure
For me, the benefits of bypass surgery outweigh the risks.	Yes	No	Unsure
I've tried medicines and lifestyle changes, and they aren't working to relieve my chest pain.	Yes	No	Unsure
I'd like to find out if other treatments would work for me.	Yes	No	Unsure
Bypass surgery is too risky for me because of my health or my age.	Yes	No	NA*
I don't understand why my doctor is advising me to have bypass surgery.	Yes	No	NA
I want to be able to exercise and do other things I enjoy.	Yes	No	NA

*NA=Not applicable

Use the following space to list any other important concerns you have about this decision.

What is your overall impression?

Your answers in the above worksheet are meant to give you a general idea of where you stand on this decision. You may have one overriding reason to have or not have bypass surgery.

Check the box below that represents your overall impression about your decision.

Leaning toward bypass surgery

Leaning away from bypass surgery

Return to the topic Coronary Artery Disease.

References

Citations
Hannan EL, et al. (2005). Long-term outcomes of coronary artery bypass grafting versus stent implantation. New England Journal of Medicine, 352(21): 2174-2183.
Yokoyama Y, et al. (2000). Association between new electrocardiographic abnormalities after coronary revascularization and five-year cardiac mortality in BARI randomized and registry patients. American Journal of Cardiology, 86(8): 819-824.
Bravata DM, et al. (2007). Systematic review: The comparative effectiveness of percutaneous coronary interventions and coronary artery bypass graft surgery. Annals of Internal Medicine, 147(10): 703-716.
Karkouti K, et al. (2001). A multivariable model for predicting the need for blood transfusion in patients undergoing first-time elective coronary artery bypass surgery. Transfusion, 41(10): 1193-1203.
Peduzzi P, et al. (1998). Twenty-two year follow-up in the VA cooperative study of coronary artery bypass surgery for stable angina. American Journal of Cardiology, 81(12): 1393-1399.
Hueb W, et al. (2007). Five-year follow-up of the Medicine, Angioplasty, or Surgery Study (MASS II): A randomized controlled clinical trial of 3 therapeutic strategies for multivessel coronary artery disease. Circulation, 115(9): 1082-1089.
Eagle KA, et al. (2004). ACC/AHA 2004 guideline update for coronary artery bypass graft surgery: Summary article. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1999 Guidelines for Coronary Artery Bypass Graft Surgery). Circulation, 110(9): 1168-1176.