European Journal of Cardiovascular Medicine

Coronary artery disease (CAD) remains one of the leading causes of morbidity and mortality worldwide, contributing significantly to the global burden of cardiovascular disease [1]. In India and other low- and middle-income countries, the incidence of CAD has risen sharply over the past decades due to changing lifestyles, urbanization, dietary transitions, and the prevalence of risk factors such as hypertension, diabetes, obesity, and smoking [2]. Coronary artery bypass grafting (CABG) has emerged as a cornerstone surgical intervention for patients with multi-vessel disease, left main coronary involvement, or those in whom percutaneous coronary interventions are unsuitable or have failed [3]. By restoring adequate myocardial perfusion, CABG aims not only to relieve symptoms such as angina and dyspnea but also to improve long-term survival and quality of life [4].

Despite significant advances in surgical techniques, cardiopulmonary bypass strategies, myocardial protection, and perioperative care, a critical question in modern cardiac surgery relates to the functional recovery of patients following CABG. Specifically, the return to pre-disease functional status — defined as the ability to perform activities of daily living, occupational tasks, and social engagement at levels comparable to those prior to the onset of disabling symptoms — has become a central measure of the true success of surgery [5]. While mortality and graft patency rates remain traditional outcome markers, contemporary cardiac surgical research has increasingly shifted toward patient-centered outcomes, including functional status, quality of life, and return to work [6].

Functional recovery following CABG is influenced by multiple factors. Adequate myocardial reperfusion plays a pivotal role, as incomplete revascularization or perioperative ischemia can impair ventricular function and delay recovery [7]. In patients who undergo complete revascularization, studies have shown a progressive decline in postoperative symptoms such as fatigue, angina, and dyspnea, with many achieving substantial improvement within 30–45 days of surgery [8]. Furthermore, structured postoperative rehabilitation programs, including supervised exercise and lifestyle modification, enhance recovery, although even in the absence of formal rehabilitation, many patients gradually return to their baseline activities within two to three months [9].

The ability to return to pre-disease functional capacity is of particular importance in working-age populations, where CAD often presents a substantial socioeconomic burden. Early recovery not only reduces dependency and psychological distress but also improves productivity and overall well-being [10]. However, there remains considerable variability in recovery trajectories, depending on patient-specific factors such as age, comorbidities, left ventricular function, graft patency, and adherence to secondary prevention strategies.

The present study examines the timeline and extent of functional recovery after CABG in a cohort of patients who achieved adequate reperfusion. By focusing on return-to-work capacity and pre-disease functional activities, this study aims to provide insights into real-world outcomes beyond conventional surgical endpoints. Understanding these recovery patterns will help optimize patient counseling, tailor rehabilitation protocols, and ultimately enhance the holistic success of CABG surgery.

Study setting & period

• Department of Cardiothoracic and Vascular Surgery, Krishna Hospital & Medical College, Karad, Maharashtra.
• Study period: January 2017 – July 2023.

Study design

• Case series of 15 consecutive CABG patients meeting study criteria.

Sample size & sampling

• Sample size: 15 cases (convenience/consecutive sampling of eligible patients during study period).
• Rationale: exploratory/observational case series; all eligible patients meeting inclusion criteria during the period were included.

Inclusion criteria

• Adults undergoing isolated or combined CABG during study period.
• Patients in whom adequate reperfusion after CABG was achieved intra-/post-operatively (see operational definition below).
• Available baseline functional status data and willingness to attend follow-up.

Exclusion criteria

• Patients with major non-cardiac co-morbidities likely to limit functional recovery independently (e.g., advanced stroke, metastatic cancer).
• Patients who died in-hospital before assessment of functional recovery.

Summary of 15 Consecutive Patients Undergoing CABG

Case 1.

A 58-year-old male presented with Canadian Cardiovascular Society (CCS) Class III angina and New York Heart Association (NYHA) Class II dyspnea on exertion, significantly limiting his daily activities and work performance. Despite optimal medical therapy, his symptoms persisted, warranting surgical intervention. He underwent elective coronary artery bypass grafting (CABG) with complete revascularization involving three grafts, performed without intraoperative complications. The immediate postoperative course was uneventful, with early mobilization and gradual resumption of routine activity. By the 30th postoperative day, the patient reported marked improvement in functional capacity, with resolution of angina and only minimal exertional fatigue. At two months follow-up, he demonstrated full return to pre-disease functional status, engaging in normal occupational duties and moderate physical activity without limitation. This case highlights the role of adequate surgical revascularization in reversing symptomatic and functional impairment, underscoring the effectiveness of CABG in restoring quality of life in patients with advanced coronary artery disease.

Case 2.

A 62-year-old male presented with severe Canadian Cardiovascular Society (CCS) Class IV angina and New York Heart Association (NYHA) Class III dyspnea, resulting in marked limitation of physical activity and significantly impaired quality of life. He was unable to perform routine daily tasks without discomfort, despite being on maximally tolerated medical therapy. Coronary angiography revealed multivessel coronary artery disease, and he was scheduled for elective coronary artery bypass grafting (CABG). He underwent four grafts with adequate revascularization, and the perioperative period remained stable without major complications. Postoperatively, he showed gradual improvement, with symptoms reducing significantly by the 35th postoperative day. At 2.5 months follow-up, the patient reported complete resolution of angina and dyspnea, regaining his ability to perform both occupational and household activities without limitation. This case demonstrates the potential of timely and adequate surgical reperfusion to restore functional capacity, even in advanced cases with severe preoperative symptom burden.

Case 3.

A 54-year-old female presented with Canadian Cardiovascular Society (CCS) Class III angina and New York Heart Association (NYHA) Class II dyspnea, both of which significantly restricted her ability to perform daily activities and household chores. She had been on regular medical management, but persistent symptoms affected her functional capacity. Coronary angiography revealed double-vessel disease, and she underwent elective coronary artery bypass grafting (CABG) with two grafts, ensuring complete revascularization. The intraoperative course was smooth, and she recovered without major complications. By the 28th postoperative day, she noted a steady decline in angina and exertional breathlessness, with gradual return to routine activity. At her two-month follow-up, she reported complete resolution of symptoms and was able to resume her pre-disease functional status, performing both occupational and household tasks without limitation. This case illustrates how adequate surgical revascularization can restore functional capacity in middle-aged women with advanced but surgically manageable coronary artery disease.

Case 4.

A 67-year-old male presented with advanced Canadian Cardiovascular Society (CCS) Class IV angina and New York Heart Association (NYHA) Class III dyspnea, with significant limitation in physical activity and frequent episodes of rest angina. His quality of life was markedly reduced, and he remained symptomatic despite being on optimal medical therapy. Coronary angiography revealed severe triple-vessel coronary artery disease, and he underwent elective coronary artery bypass grafting (CABG) with three grafts, achieving complete revascularization. The intraoperative course was uneventful, and the patient showed progressive improvement in the postoperative period. By the 40th day after surgery, his symptoms had reduced considerably, and functional capacity began improving. At three months follow-up, he reported complete resolution of angina and dyspnea, with full return to pre-disease activity levels, including resumption of occupational duties and moderate exertion without discomfort. This case emphasizes the effectiveness of CABG in restoring functional status, even in elderly patients with severe disease burden.

Case 5.

A 49-year-old male presented with Canadian Cardiovascular Society (CCS) Class II angina and New York Heart Association (NYHA) Class II dyspnea, which caused moderate limitation in physical activity and occasional discomfort during exertion. Despite medical management, his symptoms persisted, prompting further evaluation. Coronary angiography revealed double-vessel disease, and he was scheduled for elective coronary artery bypass grafting (CABG). He underwent two grafts with adequate surgical revascularization, and the intraoperative course was uneventful. Postoperatively, he demonstrated steady progress with early mobilization and gradual improvement in exercise tolerance. By the 25th postoperative day, there was significant reduction in symptoms, with improved ability to perform routine daily activities. At 1.5 months follow-up, the patient reported complete resolution of angina and dyspnea, with full restoration of pre-disease functional status. This case highlights the role of timely CABG in younger patients, enabling rapid recovery and resumption of normal activity within a short postoperative period.

Case 6.

A 71-year-old female presented with Canadian Cardiovascular Society (CCS) Class III angina and New York Heart Association (NYHA) Class III dyspnea, experiencing significant limitation of daily activities and exertional discomfort. Despite optimal medical therapy, her symptoms persisted, affecting her quality of life. Coronary angiography revealed triple-vessel disease, and she underwent elective coronary artery bypass grafting (CABG) with three grafts, ensuring complete revascularization. The perioperative course was uneventful, and she demonstrated gradual improvement in functional capacity during the postoperative period. By the 38th postoperative day, she reported noticeable reduction in angina and improved exercise tolerance. At 2.5 months follow-up, she had returned to her pre-disease functional status, performing household and moderate occupational activities without limitation. This case underscores the effectiveness of CABG in elderly female patients with advanced coronary artery disease, highlighting the potential for substantial symptomatic relief and restoration of quality of life following adequate surgical reperfusion.

Case 7.

A 60-year-old male presented with Canadian Cardiovascular Society (CCS) Class III angina and New York Heart Association (NYHA) Class II dyspnea, causing moderate limitation in daily activities and occupational performance. Despite adherence to optimal medical therapy, his symptoms persisted, warranting surgical intervention. Coronary angiography revealed triple-vessel coronary artery disease, and he underwent elective coronary artery bypass grafting (CABG) with three grafts, achieving complete revascularization. The intraoperative and immediate postoperative course was uneventful. Gradual improvement in exertional tolerance was observed, and by the 30th postoperative day, angina and breathlessness had markedly reduced. At two months follow-up, he reported full restoration of pre-disease functional status, with the ability to engage in both household and occupational activities without limitation. This case highlights the role of adequate surgical reperfusion in restoring quality of life and functional capacity in middle-aged patients with multivessel coronary artery disease, emphasizing the predictable recovery timeline following CABG.

Case 8.

A 52-year-old male presented with Canadian Cardiovascular Society (CCS) Class II angina and New York Heart Association (NYHA) Class II dyspnea, causing mild to moderate limitation in daily activities and exertional tasks. Despite optimal medical therapy, he continued to experience occasional angina during routine exertion. Coronary angiography revealed double-vessel coronary artery disease, and he was scheduled for elective coronary artery bypass grafting (CABG). He underwent two grafts with complete revascularization, and the perioperative course was smooth without major complications. Gradual improvement in symptoms was noted postoperatively, with enhanced exercise tolerance and reduction in anginal episodes. By the 27th postoperative day, the patient was performing routine activities with minimal discomfort. At 1.5 months follow-up, he reported full return to his pre-disease functional status, engaging in both occupational and household activities without limitation. This case illustrates how timely and adequate CABG can restore functional capacity even in patients with moderate coronary artery disease.

Case 9.

A 65-year-old female presented with severe Canadian Cardiovascular Society (CCS) Class IV angina and New York Heart Association (NYHA) Class III dyspnea, resulting in significant limitation of daily activities and persistent discomfort even at rest. Despite being on optimal medical therapy, she continued to experience frequent anginal episodes and exertional breathlessness. Coronary angiography revealed severe quadruple-vessel disease, and she underwent elective coronary artery bypass grafting (CABG) with four grafts, achieving complete surgical revascularization. The perioperative period was uneventful, and gradual postoperative recovery was noted. By the 42nd postoperative day, she reported substantial improvement in symptoms, with reduced angina and improved exercise tolerance. At three months follow-up, she had regained her pre-disease functional status, resuming household and moderate occupational activities without limitation. This case underscores the efficacy of CABG in elderly patients with advanced coronary artery disease, highlighting that timely and adequate reperfusion can restore both functional capacity and quality of life.

Case 10.

A 56-year-old male presented with Canadian Cardiovascular Society (CCS) Class III angina and New York Heart Association (NYHA) Class II dyspnea, causing moderate limitation in his daily and occupational activities. Despite optimal medical therapy, he continued to experience exertional angina and reduced exercise tolerance. Coronary angiography revealed triple-vessel coronary artery disease, and he underwent elective coronary artery bypass grafting (CABG) with three grafts, achieving complete revascularization. The perioperative course was uneventful, and gradual improvement in functional capacity was observed postoperatively. By the 32nd postoperative day, the patient noted significant reduction in angina and improved tolerance to physical activity. At two months follow-up, he reported full restoration of pre-disease functional status, resuming normal household and work-related activities without limitation. This case highlights the effectiveness of timely surgical reperfusion in restoring quality of life and functional capacity in middle-aged patients with multivessel coronary artery disease.

Case 11.

A 63-year-old male presented with Canadian Cardiovascular Society (CCS) Class III angina and New York Heart Association (NYHA) Class II dyspnea, causing moderate limitation in daily and occupational activities. Despite adherence to optimal medical therapy, he continued to experience exertional angina and fatigue. Coronary angiography revealed triple-vessel coronary artery disease, and he underwent elective coronary artery bypass grafting (CABG) with three grafts, achieving complete revascularization. The perioperative period was uneventful, and gradual improvement in functional capacity was observed postoperatively. By the 30th postoperative day, the patient reported marked reduction in anginal episodes and improved exercise tolerance. At two months follow-up, he had fully returned to his pre-disease functional status, engaging in both household and occupational activities without limitation. This case highlights the role of adequate surgical reperfusion in restoring functional capacity and quality of life in older patients with multivessel coronary artery disease.

Case 12.

A 59-year-old female presented with Canadian Cardiovascular Society (CCS) Class II angina and New York Heart Association (NYHA) Class II dyspnea, experiencing mild to moderate limitation in daily activities and exertional tasks. Despite optimal medical therapy, she continued to have occasional angina on exertion. Coronary angiography revealed double-vessel coronary artery disease, and she underwent elective coronary artery bypass grafting (CABG) with two grafts, achieving complete revascularization. The perioperative course was uneventful, and gradual postoperative improvement was noted. By the 26th postoperative day, she reported marked reduction in angina and improved exercise tolerance. At 1.5 months follow-up, she had fully regained her pre-disease functional status, performing both household and occupational activities without limitation. This case illustrates that timely and adequate surgical reperfusion through CABG can restore functional capacity and quality of life in patients with moderate coronary artery disease, even in older female patients.

Case 13.

A 68-year-old male presented with Canadian Cardiovascular Society (CCS) Class IV angina and New York Heart Association (NYHA) Class III dyspnea, with marked limitation of daily activities and frequent anginal episodes at rest. Despite maximal medical therapy, he remained highly symptomatic, affecting his quality of life. Coronary angiography revealed severe quadruple-vessel coronary artery disease, and he underwent elective coronary artery bypass grafting (CABG) with four grafts, achieving complete revascularization. The perioperative period was uneventful, and the patient demonstrated gradual postoperative recovery. By the 40th postoperative day, anginal episodes had significantly reduced, and exertional tolerance improved. At three months follow-up, he had returned to his pre-disease functional status, engaging in routine household and occupational activities without limitation. This case highlights the effectiveness of timely and adequate surgical reperfusion in elderly patients with advanced multivessel coronary artery disease, demonstrating that CABG can substantially restore both functional capacity and quality of life.

Case 14.

A 53-year-old male presented with Canadian Cardiovascular Society (CCS) Class III angina and New York Heart Association (NYHA) Class II dyspnea, resulting in moderate limitation of daily activities and occupational tasks. Despite adherence to optimal medical therapy, he continued to experience exertional angina and reduced exercise tolerance. Coronary angiography revealed triple-vessel coronary artery disease, and he underwent elective coronary artery bypass grafting (CABG) with three grafts, achieving complete revascularization. The perioperative course was uneventful, and gradual improvement in functional capacity was observed postoperatively. By the 28th postoperative day, the patient reported significant reduction in angina and improved tolerance to physical activity. At two months follow-up, he had fully regained his pre-disease functional status, performing household and occupational activities without limitation. This case underscores the role of adequate surgical reperfusion in restoring functional capacity and quality of life in middle-aged patients with multivessel coronary artery disease.

Case 15.

A 61-year-old female presented with Canadian Cardiovascular Society (CCS) Class III angina and New York Heart Association (NYHA) Class II dyspnea, causing moderate limitation in daily activities and household tasks. Despite optimal medical therapy, she continued to experience exertional angina and fatigue, impacting her quality of life. Coronary angiography revealed triple-vessel coronary artery disease, and she underwent elective coronary artery bypass grafting (CABG) with three grafts, achieving complete revascularization. The perioperative period was uneventful, and gradual improvement in symptoms and functional capacity was noted postoperatively. By the 35th postoperative day, she reported marked reduction in angina and improved exercise tolerance. At 2.5 months follow-up, she had returned to her pre-disease functional status, resuming household and moderate occupational activities without limitation. This case highlights the effectiveness of adequate surgical reperfusion in restoring functional capacity and quality of life in older female patients with multivessel coronary artery disease

Return to pre-disease functional status after coronary artery bypass grafting (CABG) following adequate reperfusion is a multifactorial process that depends on the interplay between successful revascularization, the extent and reversibility of pre-existing myocardial injury, perioperative myocardial protection, optimisation of systemic physiology, and a comprehensive, multidisciplinary rehabilitation strategy. At the tissue level, adequate reperfusion can salvage ischemic but viable myocardium previously rendered dysfunctional by chronic hypoperfusion (hibernation) or by transient ischemia (stunning), and the degree of functional recovery is largely determined by the proportion of myocardium that retains metabolic and contractile reserve at the time of revascularization; patients with a greater burden of viable myocardium documented on preoperative imaging (e.g., stress echocardiography, cardiac MRI, or PET) demonstrate more substantial improvement in left ventricular function and symptomatic status after CABG. [11] However, reperfusion itself is not uniformly benign—reperfusion injury mediated by oxidative stress, calcium overload, microvascular obstruction, and inflammatory cascades can paradoxically limit immediate recovery and contribute to infarct expansion unless mitigated by protective strategies applied during and after surgery. [12] Therefore, myocardial protection during cardiopulmonary bypass, timely restoration of flow through patent grafts, minimization of ischemic times, and early recognition and treatment of perioperative complications are crucial determinants of the trajectory toward pre-disease functional status. [13] Systemic factors such as perioperative anemia, hypotension, arrhythmias, respiratory complications, and renal dysfunction can further delay or blunt recovery by reducing oxygen delivery to the myocardium or increasing myocardial workload, underscoring the need for tight hemodynamic control, prompt correction of metabolic derangements, and judicious use of inotropes and vasopressors when indicated. [14] Equally important are the neurohormonal and structural remodeling processes that follow both chronic ischemia and surgical intervention: sustained neurohormonal activation—via the renin–angiotensin–aldosterone system and sympathetic overactivity—drives adverse remodeling, which may offset gains made by reperfusion; thus, early initiation and titration of guideline-directed medical therapy (ACE inhibitors/ARBs, beta-blockers, mineralocorticoid receptor antagonists, and when appropriate SGLT2 inhibitors) form the pharmacologic backbone that promotes reverse remodeling and functional recovery. [15] Beyond pharmacotherapy, restoration of pre-disease functional status requires a staged, multidisciplinary rehabilitation program that addresses cardiopulmonary conditioning, skeletal muscle deconditioning, functional mobility, and psychosocial factors; structured cardiac rehabilitation improves exercise capacity, reduces symptoms, and accelerates return to activities of daily living and work, with the greatest benefits observed when programs begin early and are tailored to the patient’s baseline fitness, comorbidities, and surgical course. [16] Objective monitoring—using serial echocardiography to track ejection fraction and wall motion, biomarker trends (e.g., natriuretic peptides, high-sensitivity troponin) to gauge myocardial stress and injury, and functional tests such as six-minute walk distance or cardiopulmonary exercise testing—permits individualized adjustment of therapy and rehabilitation intensity and helps distinguish between persistent ischemia, irreversible infarction, and reversible dysfunction due to deconditioning or pulmonary limitations. [17] Patient-specific factors also modulate the pace and completeness of recovery: advanced age, diabetes mellitus, chronic kidney disease, diffuse distal coronary disease, and prolonged preoperative heart failure duration are associated with less complete functional restitution despite technically successful reperfusion, likely reflecting a combination of microvascular dysfunction, myocardial fibrosis, and diminished regenerative capacity. [18] Conversely, timely revascularization in patients with shorter durations of ischemia, preserved microvascular integrity, and fewer comorbidities predicts a higher likelihood of returning to baseline function. Surgical factors—graft selection and quality (arterial versus venous conduits), target vessel size and runoff, and completeness of revascularization—directly influence myocardial perfusion and thus functional outcomes; long-term graft patency, particularly of arterial grafts, correlates with sustained symptomatic and functional improvement and reduced need for repeat interventions. [19] Finally, psychosocial determinants—depression, social support, health literacy, and adherence to lifestyle modifications (smoking cessation, dietary changes, weight management)—play a pivotal role in translating physiologic recovery into meaningful, sustained gains in daily function and quality of life; incorporating behavioral health support and patient education into postoperative care enhances engagement with rehabilitation and adherence to secondary prevention, thereby improving long-term outcomes. [20] In sum, achieving return to pre-disease functional status after CABG is not a singular surgical success but the product of comprehensive perioperative care that ensures effective reperfusion while minimizing reperfusion injury, aggressive optimization of medical therapy to facilitate reverse remodeling, vigilant management of systemic complications, targeted rehabilitation to rebuild cardiopulmonary and musculoskeletal capacity, and attention to patient-specific anatomic, metabolic, and psychosocial factors that influence recovery; when these elements are aligned—guided by objective imaging, biomarkers, and functional assessments—many patients can expect substantial restoration of function, though the degree and timeline of recovery will vary according to the burden of irreversible myocardial damage and the presence of comorbid conditions.

Based on the presented cases, it is evident that elective coronary artery bypass grafting (CABG) with complete surgical revascularization leads to consistent and substantial improvement in functional status and quality of life across a wide spectrum of patients with advanced coronary artery disease. Regardless of age, sex, baseline symptom severity, or number of diseased vessels, patients experienced progressive reduction in angina and exertional dyspnea during the early postoperative period, with most noting significant improvement within 25–40 days after surgery. By 1.5 to 3 months follow-up, nearly all patients had returned to their pre-disease functional status, resuming household, occupational, and moderate physical activities without limitation. These outcomes underscore that timely and adequate surgical reperfusion not only alleviates symptoms but also restores physical capacity, enabling patients to regain independence and normal daily functioning. The predictable recovery trajectory observed across cases highlights the reliability of CABG in reversing symptomatic and functional impairment, emphasizing its role as a cornerstone intervention in managing multivessel and severe coronary artery disease.

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