Heart Bypass Surgery
Heart Bypass Surgery is an open-heart surgery that is used to treat blockages of the heart arteries. When there is a heart artery blockage, blood supply to areas of the heart are affected. A heart bypass is attached beyond the blockage restoring blood flow to that area. Heart bypasses are either arteries or veins taken from other parts of the body including the chest wall and the legs. This article is a picture guide to heart bypass surgery that takes you through many critical stages of the operation.
heart bypass surgery beating heart with bypass attached
Coronary artery bypass grafts; three grafts are depicted here, a left internal mammary artery (LIMA) to left anterior descending (LAD) and two saphenous vein grafts – one to the right coronary artery (RCA) system and one to the obtuse marginal (OM) system. The LIMA graft is surrounded by yellow fatty tissue in the forefront of the diagram, the RCA graft departs the left side of the aorta and wraps around the heart on the left side of the diagram, the OM graft departs the right side of the aorta and wraps around the heart on the right side of the diagram.
The Heart Bypass Vessel
The most well known bypass is called the LIMA to LAD. LIMA stands for left internal mammary artery and is an artery that runs from the left collarbone area down the chest wall. LAD stands for left anterior descending artery which is the artery commonly responsible for the ‘Widowmaker Blockage.” In a bypass it is carefully taken down from the chest wall and attached beyond a blockage acting as a bypass. The LIMA to LAD is very successful as a bypass and has good long-term results. In other types of bypasses, arteries can be taken from the forearm, or veins can be taken from the legs. Read this article on heart blockages and this article on the ‘Widowmaker” for more information. This article titled “how long does a bypass last” is useful and goes in to a little more depth about the different bypasses.
The Left Internal Mammary Artery (LIMA) is depicted here and is labelled #8.
Heart Bypass Surgery – A Picture Guide
Heart Bypass surgery Cutting superficial with electocautery
Cutting The Skin
The first operative step in a heart bypass surgery is cutting the chest wall to expose the breastbone. A scalpel is used initially. Then electrocautery is used to dissect through the superficial layers. In these images the superficial tissues are dissected through, then the deeper layers down to the breastbone.
Heart Bypass Cutting To Breastbone With Electrocautery
Sawing Open The Breastbone
Heart bypass surgery is an open-heart surgery and the heart needs to be exposed. In the case of bypass surgery this is done by sawing through the breastbone in a technique known as median sternotomy. A specially designed electric saw is used for this. A median sternotomy is demonstrated in the next image. Once the bone is cut, small bleeders are cauterized to stop the bleeding.
Heart Bypass Surgery Electric Saw Through Breastbone
Heart bypass surgery cauterizing bleeding breastbone vessels
Freeing Up the LIMA
As described above, the best bypass to use when possible is known as the LIMA. This runs on the left inner chest wall. In this next image the breastbone on the left is retracted and then the LIMA is freed up from the chest wall so it can be used as a bypass.
Heart Bypass Surgery Retracting the Breastbone
heart bypass surgery cauterizing bleeders under the chest wall
Harvesting The Leg Vein
In the old days of heart bypass surgery the leg was literally cut open to expose then harvest the leg veins to be used as bypasses. A more modern technique is known as endoscopic harvest where a small endoscope is inserted in to the leg and a keyhole technique is used to take out the vein to be used as a bypass. This leaves us with a much smaller leg wound and improved healing with less complication.
heat bypass surgery keyhole leg vein harvest
hyeart bypass surgery vein after endoscopic harvest
Heart Bypass Surgery Keyhole leg vein harvest
heart bypass surgery keyhole leg vein harvest 2
Putting the Patient On Cardiopulmonary Bypass
The patient undergoing heart bypass surgery is placed on a heart lung bypass machine to take over the work of the heart during the operation. This allows the heart to be stopped. Some people advocate doing heart bypass surgery on a beating heart, most do not, it is an ongoing debate with no clear winner.
Preparing The Heart Bypasses
The bypasses are cut appropriately. The small branches on the side are clipped so blood isn’t lost when they are attached. The veins are expanded with fluid to ensure they are competent for use.
heart bypass surgery preparing the vein to use as a bypass
Attaching The Bypasses
The arteries to be bypassed are carefully exposed. The bypass grafts are then carefully attached. Good technique here is critical to ensure good results.
heart bypass surgery carefully exposing the blocked artery
heart bypass surgery attaching the bypass graft
Other Operations
In many patients other operations will be needed at the same time. Patients with mitral regurgitation (a leaky mitral valve) or mitral stenosis (a tight mitral valve) may need mitral valve repair or mitral valve replacement at the same time. Patients with aortic stenosis or aortic regurgitation may need aortic valve replacement at the same time also.
Restarting The Heart
Once the heart bypasses are attached the heart can be restarted so it can start beating again in its normal fashion.
heart bypass surgery beating heart with bypass attached
Closing The Chest
The breastbone is closed using a technique known as sternal wiring to hold it together until it heals over time. After that the superficial tissues and the skin can be sutured together. Drains are left in the heart sac and the lungs to allow drainage of blood over the next 24-48 hours.
heart bypass surgery wiring the breastbone back together
heart bypass surgery closing skin and placing drains
To The ICU
After heart bypass surgery the patient will be transported to the cardiac intensive care unit. The breathing tube is typically taken out the same day. Patients are typically in the hospital 3-5 days after heart bypass surgery.
This article was extremely helpful in understanding just what will happen during surgery. It is very informative.
I had a triple heart bypass in March 2022, except for the first month after surgery that I was weak, didn’t have any pain or problem. Being a single male, I did my daily chore and after 2nd month I continued with my daily jugging. I will continue with Cholesterol and blood pressure for a few more months and will decide about medication when time comes. By the way, I’m 78 active and never had heart problem.
The video was very informative to me as I had a double bypass & a aortic valve replaced.
The video was very informative to me as I had a double bypass & a aortic valve replaced.
I had triple by-pass surgery 12 years ago and now the arteries are blocked again even after losing 80 pounds, taking medications faithfully, etc. Is it possible to have more surgery?
Redo bypass surgery is certainly possible if required but depends on many factors including the health of the patient and the condition of the heart. These situations require a good work up. This may include viability testing to see if the heart tissue is viable and would benefit from reestablishing blood supply. There have been significant advances in stent technology also and there may be options such as CTO procedures.
Given the large amount of people we have been able to help here, we are starting a twitter to help keep heart patients up to date with advances and relevant information. Mine can be followed at @MustafaAhmedMD
Dr, you are truly amazing. Any person that can do what you do, is true royality of your field. To know all that you know, do what you do — words cannot express your talent. You are one of a kind….. Very few people have your calling and for that I thank you from the bottom of my heart. Jesus loves you and so do I!!!
Sir, on April 24 the my mother admitted for triple vessel disease, MR, LVF and advised CABG, but as surgeon was not available they told us to go to other hospital. But there instead of surgery they forced us for stent procedure saying that surgery was risky.On 6 th May 2 hrs after placing 2 stents we lost our mother, we don’t know the exact reason also sir. Please please give your valuable opinion sir reg this.
very sorry to hear this, i really would advise you make an appointment with the treating team to discuss this.
Disclaimer: The comment response is opinion and in no way affiliated with my employer. It is a vague response that is not to be used as direct medical advice and in no way should replace the opinion of a medical provider.
What’s better for a 100% blocked LAD? LIMA or stent?
It differs in every case and i would need to see the films and know the story to comment. In most cases, if a good sized LAD and totally occluded, LIMA is a good option given its longevity, particularly if the disease is considered conplex.
Given the large amount of people we have been able to help here, we are starting a twitter to help keep heart patients up to date with advances and relevant information. Mine can be followed at @MustafaAhmedMD
On December 6, 2016 I had a triple bypass with less than 24 hours notice. I have a thorough understanding of the procedure, but it was very enlightening to watch the video clips. My dad had a double bypass in 1978 and I’m amazed that this type of surgery is even possible, especially in 1978. I’m just so grateful to be alive!
Glad you found it useful.
you can follow my twitter at @MustafaAhmedMD
I just am two months out from triple bypass and thankful to have seen these clips. On purpose i had avoided knowing the specifics. Evry day im closer to being whole. It was an eye opener.im hopeing for many more years. My uncle had this surgery 25 years ago and is still in the move in his 90zzz.blessings on you and us as well
I, too, had triple bypass, in Oct 2015.
The pictures here were some of the
best I have seen to help understand
visually what goes on! Thanks!
How And how is your dad now
My dad went through the surgery but he had complication with internal bleeding. The doctor said the blood was not flowing through his bowel and they had to remove 80% of his bowel post surgery. Is this a Known complication ? Was there any preventive they can have done to help save my dad?
Very sorry to hear that. Difficult to comment without knowing specifics. This can occasionally be seen in cases where the overall blood supply to the bowels is diseased beforehand or where there is prolonged periods of low blood pressure.
My wife had a quadruple bypass 6 years ago at age 55.. How long can we expect her procedure to last? I’ve heard anywhere from 10-15 years. Is that correct?
Many bypasses can last a lot longer. Its important to continue medical and lifestyle treatment the whole while.
you can follow our twitter at @MustafaAhmedMD
I had a quad cabg procedure 20÷ years ago and with exercise and diet I’m great. I was 53 at the time. Exercise was mostly more walking
Hello Dr.Mustafa Sir,
I am Mohamed Mufeezulla khan, recently two days ago my mother again got an heart attack, before twice heart attack happened to her in the same place, this is the third time. They have put twice the stent, again it is blocked. Doctor giving us 2 option. They can able to Bypass Surgery or they will put balloon. I am worried about this. My mother age is above 50 years. Also she is not strong. They are discharging today and said will give the date to do the operation. Kindly suggest me which is better. What should I decide, whether Bypass surgery or shall I ask them to put balloon. My father is no more, only my mother is everything for me. I believe on ALLAH next on Doctor. If possible, please let me know the advise as soon as possible. They are saying Bypass is a risk, if it is get success there would be a guarantee for 10 years and for the balloon for 2 years guarantee. But they saying as if they put the Balloon again there would be a chance for the blockage.
Thanks & Regards,
Mohamed Mufeez
Depends on the local recommendation and the patient condition, however if balloon has already failed then a surgical option may be important.
you can follow our twitter at @MustafaAhmedMD
Had bypass surgery in Oct 2017 healed fine no problem.
My leg where they took vein, is still causing me pain.
Where the incision is. A band is numb around my ankle.
Calf gets cramped
Pain gets to the point can’t lift leg .
My question is is this normal healing?
You should get that evaluated and other issues ruled out.
you can follow our twitter at @mustafaahmedmd
by pass surgery 7 weeks ago, chest healing good, but leg incision is still open and looks raw
should I treat it with something and keep it bandaged or just leave it alone and no bandage
It needs to be evaluated by the treating surgical team.
you can follow our twitter at @MustafaAhmedMD
I had a triple bypass on April 5, 2018 I am still in a lot of discomfort in my chest and my left leg where the vein was harvest is still a sleep I am still getting sharp pain at night down my left leg. Is this normal. I am only 20% percent the active woman I was prior to my surprise surgery. What should I do next.
Start by making an appointment with the treating surgeon to review the wound and leg.
you can follow our twitter at @MustafaAhmedMD
In 22 December 2016 I had a redo CABG through a left thoracotomy where a graft was inserted at the end of a vein graft where one of the good bifurcation vein was admitted with a 1.5mm shunt.
Following this procedure chest pain vanished and despite two years of daily long walking, chain pain was being felt occasionally whenever i exercised. My cardiologist referred me to stress echo and CT scan and blood tests and ended up adding doubling my beta blocker (bisoprolol fumerate to 5mm daily, 375mg of Ranexa to be taken twice daily every 12 hours and 25mg of spironolactone on top of the other medication that i was one i.e 10mg ramipril, crestor 20mg, ezetralex, 70mg aspirin. In his report my cardiologist stated that if chest pain started recurring he will raise Ranexa to 500mg twice a day and if this fail he will go for PCI using eluding drugs. Two years ago my cardiologue has informed me that inserting the stent is difficult and could be risky because the mamal graft that was used to the LAD is tortuous and that is why when the same Ranexa drug that he gave me then failed to stop the chest pain he recommended to do the graft through the back.
in 1985 i had my first CABG where three graft were inserted using 1 sephanous vein to the OM and two mamal ones to the LAD and RCA. The sephaneous occluded about 12 yeard aog.
Opening the chest for the redo was considered inappropriate.
I can send you the report of the CT scan and stress echo.
The EF was 43% a reduction from 47% before the redo cabg. The report of the CT talked about recersible stenosis and diffuse atheroma on the LAD after the LIMA.
Please let me have an opinion especially about the stenting
Its not really possible to comment technically without seeing the cath films. Have you seeked a second opinion from an interventional specialist?
you can follow our twitter at @MustafaAhmedMD
My Uncle is 65 years of age and he do smoking and Very few times drinking. Now he had a bypass surgery as he got mild attack the day before the surgery and he is too weak ,has also some health problems like slight gladbladder stones ,blockages in veins in some of the body parts and also it affe ted some organs too …now he is affecting with infection after 24hrz of surgery nd doc told that they will put a balloon using vein in the leg and after that they said that leg wont work…is this okay ..or anything else to be done
My dad has 100% occlusion of all 3 coronary artery and is scheduled for CABG in two weeks. He is not having any pain, his blood pressure is under control with meds and he is still in denial of necessity of surgery. How can I explain to him what are his choices and prognosis regarding pros and cons of operation?
My dad had three heart blockage I heard this 3 years before at srm hospital …..in that hospital doctors said CABG was need to done then we didn’t accept that surgery but now he took the prevention….it’s better or not…….becz bypass surgery causes so many complication…. already he took medication for psychiatrist…..my dad has above 55.Older…. but he is good…..pls tell me any suggestions….I need my dad want to cure without any operation….
I would at least recommend a second opinion from a non interventional heart specialist.
You can follow our twitter at @MustafaAhmedMD
Disclaimer: The comment response is opinion and in no way affiliated with my employer. It is a vague response that is not to be used as direct medical advice and in no way should replace the opinion of a medical provider.
My husband had a quadruple bypass on June 19th at the age of 40. His grandfather had the same surgery at the same age as him. Joe is doing great, didn’t really want to see these videos. I was the curious one! Without doctors like this I wouldn’t have him anymore. So, thank you!
I just had a I had a triple bypass done and it seems everything went well. its different if it gets explained or if you actual see whats happened. Is it legal to copy the whole webside including movies ?
Since when has CABG been “open heart surgery” as far as I know the coronary arteries are on the outside of the heart. That would be open chest surgery.
Was nice to see how it all goes on , shame i could not have a video of mine LOL
I had a triple bypass in 2000 at Sunninghill Hospitall by Dr Kruger, perfect gentleman and brilliant surgeon, I was 57yrs at the time and I have had no problems with my heart since, this is the first time that I have actually seen the procedure, quite fascinating, anyone who has family that is having a bypass no need to worry, I have since had a back operation (2004) and trust me I would rather the bypass
Thank you kindly for the information, especially the video images.
2008 sam imao operaciju trosudovna koronarna bolest LIMA LAD ,RCA-PDA,CX-OM1,i do sada sam bio izvrsno sada osjećam povremeno gušenje bez bola ,pitam koji bi to bio najbolji način kontrole baypasa i dugotrajnost premosnica
What no nanobots?
So the plaque in the arteries is still there after the operation? They just make a different route to it?
Dr. Ahmed, I have just recently been found with full obstruction in the LAD. The obstruction is at the top of the heart. They attempted to place a stint but the blockage was too thick. I am to meet with the doctor’s 9 /16 to discuss a plan to correct it. I had been told that I was not a candidate for bypass of open heart surgery, but from what I’ve read CABG with LIMA may be my best bet. I am 58 yrs. old, non-smoker, with high-blood pressure. I really want to go into this appointment asking the right questions.
Donna Sinclair
Hi Dr Mustafa Ahmad I had bypass surgery back in December of 2012. Prior to going into surgery I had a burning sensation on the left side of my chest. The surgeon used the LIMA and the RIMA to bypass the areas that were clogged. Last year in May of 2019 the burning sensation came back and I admitted myself back in the hospital. Upon doing the angiogram the surgeon discovered that both arteries the LIMA and the RIMA where 90 percent occluded and he didn’t want to stent them in fear of perforating them. He told me that my situation was unique case in that he’s never seen where both arteries failed at the same time. So instead of stenting the arteries he stent the original arteries the LAD and the Left Main Artery. My question is what happens to the Lima and the Rima in the body? I religiously eat clean and workout. The other question I have is what’s the point of taking statins ( Crestor) when they didn’t help prevent arteries from clotting. Thank Mike
I am eighty and had five bypasses thirty five years ago and numerous intervensions since then. All bypasses including the ramos are now closed and inoperable! The one remaining open is the L.A.D. bypassed using the mammary artery thirty five years ago! Living proof that the use of the mammary artery is a life extender!
How can my bypass veins be checked to see if they a starting to get blocked? I had a triple bypass a year ago.
Thanks,
Ray
Hi
I had a heart attack and my ef was 20% after that. Six months later the echo was done and the ef was 30% _35% and surgery was performed. One week after surgery ef 20%, two months 30% _25% and 9 months after surgery 25%. What do you think is the reason for not increasing ef?
I was told that the ef increase in surgery is greater than the stent, but this has not happened now.
Does this value ef remain constant?
Thanks
Hi
I read your article and I have a question, is it not possible to graft lad with svg?
Thanks
very informative, answers to what I was thinking about. Thank you
patient with CABG in 2000,LIMA to LAD and RCA graft.RCA graft occluded 100%.CTO to native RCA 2019 successful.Had a LVEF 52 in 2018.After taking COREG for 60 days in may 2021,the LVEF is 37% ,Its CHF stage 3.Any suggestion to improve and /or stabalize LVEF .limited options of some meds like entresto low dosag,because of Orthoststic hypo.
I recently had a CT Angiogram. My total CAC score was 401. My LAD was a 311, Right Coronary Artery was a 88 and the Left Circumflex coronary artery was a 2.0.
My doctor is out of town for two weeks and I’m just trying to figure what all of this means and what the most likely fix will be for it.
Thank you so much for what you do.
I am 80 years old with good health status, however with CAD and 6 cardio stents:
The 2 stents on RCA and the one on Circumflex are OK. The 2 stents on LAD are also OK, however Diagonal D1 is 100% blocked. The 2 stents on LAD are very close to Blocked D1, and one of the is partially inserted in the first LAD stent. Do you recommend trying to open D1 and if not successful LIMA to LAD bypass? My Left main artery is 30% blocked
Great article, especially the videos. wished I had seen this before my op, but, still now I can understand more what happened and what to expect during recovery at home. I had a triple bypass 4 months ago, seen cardiologist few weeks ago and was discharged from further appointments. Feeling great apart from long covid and bad spinal stenosis which slow down recovery, but, definitely feeling better after the op.
Thanks for the article and videos
Excellent presentation. CABGx3 two and one half years ago (3/1/2020). Absolute textbook case, fortunately for me.
I thoroughly enjoyed this.
Thanks for the succinct production.
My husband recently had a quintuple bypass performed. Three of the grafts were on the LAD: the LIMA artery for the “main” part of the LAD and then two vein grafts on two of the diagonal parts of the LAD where there were blockages. Is this typical? Will long-term prognosis be just as good as if it were just the one LIMA graft? Any insights are very much appreciated.
Amazing Dr Ahmed. Your service to society is worthy of emulation.
A theoretical question- I underwent open heart surgery in July,06 at a reputed Hospital in Bengaluru, India.
LIMA-LAD and SVG-OM.
It is suspected that SVG has thickened. Would it be true? Does the solution lie in stenting ? I am taking Angispan TR,Vymada 50 mg and Ecospirin AV from the last one week.
Kindly advise.
Thank you and with regards,
d ravi shankar(70)
Dear Dr Ahmed,
Is Robotic CABG as effective as Conventional CABG?
Thanks!
Hello I had a quad bypass in Dec 2020. There were problems with the diaphragm muscle, left side not working properly which I am told is now healed though breathing is occasionally difficult. The main problem following the op is psychological. During the ICU recovery i suffered consistent deep visual and aural effects. At their worst I heard the staff plotting against me, and watched the walls melting. Since then I suffer rages and continuous paranoia. Do others report similar problems and is there a medical or social support group?
In the pre-surgery events, is the STS calculation ever not done? It seems to me it would be an important factor in obtaining bedside consent but I am told it is elective. Does the STS calculation ever enhance or cause more caution during surgery? Can the STS calculation have a negative effect like unnecessary caution making surgery longer? On the other side of surgery, is it better to extubate right after surgery to lessen vent time or to wait until the sedatives wear off in ICU? I ask because I get one story from a cardiac recovery nurse who is a relative in another state and another story from an ICU recovery nurse in the state where I reside.
Thank you for your time, knowledge, and personal opinion.
07/07/2023 My best friend of over 40 years just came out of surgery for a triple by-pass. She is now in the recovery room, and I hope and pray she will do well. I decided to find out more about what happens during a by-pass. I just read and viewed the information about what happens during this surgery. I am in awe, and so grateful for the knowledge and skills all surgeons and nurses have to do this kind of surgery. I didn’t realize how complicated it was. Thank you to all these medical people who save the lives of our loved ones everyday.
This is one of the options that my cardiologist and I are discussing. To be honest, this procedure scares me as my grandmother passed away after having a stroke during the bypass surgery (albeit, that was over 30 years ago, so I am assuming there have been advances in the procedure.) What scares me most is that I have been told that there are negative psychological effects afterwards. I don’t know if this true or not, so does this procedure cause psychological issues to the patient?
I was catheterized and three days ago and was told that calcification prevented stent placement. I was told that 5 coronary arteries are blocked 90%. I have been on a whole food plant based diet for the five years that CAD was identified. A month an a half ago I developed artrial flutter with a couple of episodes of very high blood pressure, but other than occasional mile angina, since I developed the flutter, I have never felt any light headedness, dizziness, fatigue or a heart attack. Is it possible that my heart has devloped a network of smaller vessels to nourish it? I am scheduled for by pass surgery in a week and a half. Does it make sense to go ahead with the surgery or should I first try to solve the atrial flutter. My cardiologist has said that he feels that the reason I developed flutter is that my heart is unhappy with the limited flood supply
How is the new blood vessel attached to the artery? Does it actually fit into the artery? Is the damaged section of each artery removed? How is the actual space inside the area of the heart, i.e. after the new section is added? Is there room without any rubbing causing friction and possible damage to the new section? Can tapes be used instead of wire to close the breast bone? How successful is the tape? Is the pericardium closed up, or left open and eventually closes/joins itself? Are the drainage tubes actually left inside, or is an end of each outside so that it can eventually be pulled away?
On March 25,2026 I had a CABG x4 three arteries blocked 90% and one blocked 50. The one blocked 50 had two stents put in 10 yrs prior. Heart disease runs in my family. My oldest son passed away in his sleep and when an autopsy was performed they found both RCA and LCA blocked 90%. Right after he passed I when to a cardiologist and that’s when I had two stents put in. Fast forward 10 years and I had to have a quadruple bypass. I’m thinking because I am Native American (Tlingit / Filipino) from Alaska and now live in Washington for the past 25 yrs and all the bad food I eat. Crazy thing is I’m very active and I only weight 160 lbs. the heaviest I was up to 175ish. I am 60 yrs old and my Cardio Surgeon at Virginia Mason (Seattle WA) was very pleased with how I recovered after surgery even tho they had to open me back up after the first surgery because I had micro bleeding. Anyway I am doing well except my right leg where the vain was harvested from is still very sore and a little swollen still.
I just wanted to share my story and thank all the doctors that are in this field and helping folks with a new lease on life. I’m 60 yo and look forward to another 20+ years.
Thank again for all that you and the rest of the doctors, nurses, CNA’s and the rest of the staff. I had a wonderful experience at Virginia Mason.
Bless you all, Randy