The Enid News and Eagle, Enid, OK

January 9, 2013

Having heart surgery — emergency and otherwise

By Judy Rupp, columnist
Enid News and Eagle

— 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. He 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.

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. This occurs because not enough oxygen-rich blood is getting through the blood vessels to meet the needs of the heart.

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 coronary artery bypass graft surgery (CABG) may be necessary.

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.?

Traditionally, the blood vessel graft was nearly always taken from the saphenous vein in the leg. 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 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 (known as “keyhole” surgery), performed through a three-inch incision.

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.

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.

Rupp is a certified information and referral specialist on aging for NODA Area Agency on Aging. Contact her at 237-2236.