Edward told the doctor he had been “a little short of breath” while working in the garden recently; “I just want to check things out to stay on the safe side,” he said.
It didn’t take the doctor long to discover that Edward was on the far side of safe. “You have blockages in your coronary arteries so great that I can’t believe you’re still walking around,” the doctor said.
Edward was told to report to the hospital the next day for open heart surgery. That was 15 years ago, when Edward was a mere 82; he is still walking around today at age 97.
About 500,000 Americans undergo coronary artery bypass graft surgery every year. Some are in the middle of a heart attack when surgery is performed; others are considered at high risk because of significant narrowing of the arteries that provide blood flow to the heart. Not all come out as unscathed as Edward did, but there is no question that the procedure saves lives and improves quality of life.
The need occurs when one or more of the arteries servicing the heart becomes narrowed by atherosclerotic plaque. The narrowing may occur gradually over many years, but when 50 to 75 percent of the vessel becomes blocked, the patient is likely to experience symptoms such as chest pain or shortness of breath when exercising or performing daily activities such as gardening or climbing stairs. This occurs because not enough oxygen-rich blood is getting through the blood vessels to meet the needs of the heart.
A few individuals, such as Edward, experience no symptoms or only mild ones and are at risk of suffering what is called a “silent heart attack”–often deadly because it gives no warning.
Medical Treatment Is Best
When coronary artery disease is detected early enough, it can be treated with lifestyle changes (diet and exercise) and medication. But when blockages continue to get worse despite these measures, more invasive approaches such as balloon angioplasty or heart surgery may be necessary.
As anti-cholesterol medications have become increasingly effective in reducing blockages, both angioplasty and coronary artery bypass graft surgery (CABG) are more commonly used today to treat a heart attack in progress rather than to improve quality of life.
The name tells it all: blood flow through the coronary artery is restored by taking a graft from another, non-diseased blood vessel and suturing it into the coronary artery to bypass the blockage. You’ve probably heard of double, triple, quadruple or even quintuple bypass surgery–depending on how many arteries near the heart are blocked and how many are repaired.
The procedure is complex and time-consuming, requiring about three to six hours in the operating room.
To reach the heart, the surgeon makes an incision down the middle of the chest and then saws through the breastbone. The main aorta is clamped off, and the pumping action of the heart is taken over by a heart-lung machine. The heart is cooled with iced salt water to minimize damage during surgery.
Traditionally, the blood vessel graft was nearly always taken from the saphenous vein in the leg. More recently, doctors have preferred to use chest wall arteries such as the left internal mammary artery. These are not only nearer and easier to connect but also have been found to remain open longer after surgery. Ten years later, 90 percent of these grafts are still open, compared to only 66 percent of vein grafts.
After the grafts have all been sutured in place, the breast bone is wired together and the incision is sewn shut. Complications such as bleeding or irregular rhythms can occur in the first few days after surgery; even so, the average length of stay has been reduced to three or four days for most patients.
More serious complications can occur in the days or weeks after surgery–heart attack, stroke, memory loss, confusion, infections and death. Many of these complications occur as a result of stoppage of the heart.
To address these problems, off-pump bypass surgery was developed and is now used for about 20 percent of cases. Using suction or compression, the surgeon can stop only a small portion of the heart, allowing the beating to continue.
This approach is at least as effective as traditional surgery, according to research, and has been linked to fewer short-term complications. Some patients are better suited than others to off-pump surgery, however.
Another advance is minimally invasive heart bypass surgery (also known as “keyhole” surgery), performed through a three-inch incision. Advantages include a smaller scar, shorter hospital stay and quicker recovery. Minimally invasive surgery can also be performed with robotic-assisted techniques and a beating heart.
Successful coronary artery bypass graft surgery can make a significant improvement in the patient’s quality of life, reducing symptoms such as chest pain and shortness of breath and decreasing the risk of a heart attack. Treatment of coronary artery disease, however, involves a commitment to a heart-healthy lifestyle. Edward followed his rehabilitation program and made permanent changes in his diet and exercise habits.
For a heart attack in progress, either angioplasty or CABG, performed in an emergency environment, is now considered an effective option for quickly restoring blood flow through coronary arteries. Although angioplasty is quicker, less invasive and carries fewer risks, bypass surgery is usually favored for patients with narrowing of the left main coronary artery or narrowing of three or more vessels. Diabetes patients may also do better with surgery.
In some cases, too, emergency angioplasty fails, and bypass surgery must be performed as a backup life-saving measure.
For emergency CABG, studies have found that off-pump beating heart surgery is a valid option with a significantly lower rate of mortality and morbidity.
Overall, about three to four percent of patients undergoing bypass surgery die, either during the procedure or shortly thereafter–most commonly because of a heart attack. It is not a procedure to take lightly; and it rarely is. When coronary arteries are narrowed by 90 percent or greater–as in Edward’s case–or when they are completely blocked–as in a heart attack–it can save lives.
REFERENCES:
Michael S. Barakate, FRACS, et al, “Emergency surgery after unsuccessful coronary angioplasty: a review of 15 years’ experience,” The Annals of Thoracic Surgery, 2003;75:1400-1405.
Patrick A. Calvert and P. Gabriel Steg, “Towards evidence-based percutaneous coronary interventions,” European Heart Journal, 2012;33(15):1878-1885.
“Coronary artery bypass surgery,” Cleveland Clinic, 2012.
Mark A. de Belder, “Interventional management of acute coronary syndromes: applying the lessons of ST-elevation services to non-ST-elevation myocardial infarction,” Heart, 2012;98(19):1407-1411.
Enrico Ferrari, et al, “On-pump beating heart coronary surgery for high risk patients requiring emergency multiple coronary artery bypass grafting,” Journal of Cardiothoracic Surgery, July 2, 2008.
Gary Gerstenblith, M.D., and Simeon Margolis, M.D., Ph.D., “Coronary heart disease,” Johns Hopkins White Papers, 2012.
“Heart disease and coronary artery bypass surgery,” WebMD Medical Reference, reviewed by James Beckerman, M.D., FACC, May 12, 2012.
Daniel Lee Kulick, M.D., FACC, FSCAI, “Coronary arterybypass graft surgery,” MedicineNet.com., last editorial review May 7, 2007.
National Heart Lung and Blood Institute, “What is coronary arery bypass grafting?” NIH, February 23, 2012.
Dumbor L. Ngaage, et al, “Early and late survival aftersurgical revascularization for left main coronary artery stenosis in stent era,” British Journal of Cardiology, 2012;19(3):134-138.
Caroline Price, “Emergency CABG ‘reasonable approach’ in AMI,” Medwire news, December 8, 2009.
Ardawan Julian Rastan, et al, “Emergency coronary artery bypass graft surgery for acute coronary syndrome: beating heart versus conventional cardioplegic cardiac arrest strategies,” Circulation, 2006;114:I-477-I-485.
Eric H. Yang, et al, “Emergency coronary artery bypass surgery for percutaneous coronary interventions: changes in the incidence, clinical characteristics, and indications from 1979 to 2003,” Journal of the American College of Cardiology, 2005;46(11):2004-2009.
11/29/2012
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