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The Future of Your Heart Attack

BUT SUPPOSE CLEANER LIVING DOESN'T DO IT AND THE MRI'S KEEP SHOWING A PROBLEM. IS THERE ANYTHING MORE WE CAN DO ABOUT IT, SHORT OF OPEN-HEART SURGERY? continued...

True, the procedure has a checkered reputation. First heralded as a civilized alternative to open-heart bypass when it showed up on the scene in the late seventies, it quickly proved disappointing, since the rehabilitated vessels of almost half of all patients reclogged within six months to a year, necessitating another angioplasty and, in some cases, the dreaded open-heart surgery. But the widespread use of stents--tiny wire-mesh tubes that are inserted into the freshly expanded blood vessel to fortify it against renarrowing--over the past decade or so has not only restored angioplasty's reputation but also taken it to the top of many cardiologists' lists of potential treatments for all but the most advanced blockages.

According to the American Heart Association, heart patients who receive angioplasty plus stents these days have a 40 percent lower chance of needing an additional angioplasty or open-heart surgery than their fellow patients who underwent angioplasty with no stents back in the eighties. And according to the Cleveland Clinic Heart Center--named the best heart hospital in the nation by US News & World Report eight times in the past decade--angioplasties have become so reliable that the number of open-heart surgeries performed is expected to drop 5 to 10 percent per year over the next decade. Moreover, increased trust in angioplasty is encouraging its use preventively, which is to say, on those many patients who have serious coronary-artery disease but are not yet at Imminent risk of a heart attack. The idea of prophylactic surgery--actually getting your body rearranged in some fairly major way merely in anticipation of a life-threatening problem--may strike you as a little creepy. But one reason that heart disease remains our number-one killer is that its treatment has always been reactive. New and better imaging devices, coupled with a simple day surgery like angioplasty, allow cardiologists to treat the disease proactively, preventing both heart attacks and the gruesome open-heart surgery that they call for.

 

IF I'M BEYOND ANGIOPLASTY, I'M HEADED FOR THE SLAUGHTERHOUSE, RIGHT?

Well, you're going to have to be opened up, but there's a good chance it won't be as brutal as it was for previous generations of heart-surgery patients. Over the past decade, minimally invasive bypass surgery has quietly become one of the most important breakthroughs in the treatment of heart disease. There are three key innovations that have made minimally invasive approaches both more effective and easier on the patients.

  1. Surgeons finally figured out that harvesting the saphenous veins from the lower legs for the revascularization of clogged coronary arteries was counterproductive in two ways. One was that it tended to leave a lot of heart-surgery patients almost crippled; the other was that the venous tissue--generally weaker than arterial tissue because it carries blood back to the heart at a much lower pressure than it is carried out by the arteries--tended to reclog within ten or fifteen years, necessitating another open-heart procedure.

About ten years ago, surgeons discovered that simply pulling over a section of one or both internal mammary arteries was not only simpler but also provided much sturdier bypass tissue. And if more than two bypasses were required, the radial arteries of the arms could be used. "We can provide a quadruple bypass using only arterial vessels, and nearby ones at that," says Cleveland Clinic's chairman of cardiovascular surgery, Dr. Delos M. Cosgrove. "It leaves the patient's legs intact and lasts up to twenty years."

  1. In many surgeries, a full sternotomy--the infamous splaying open of the rib cage to get at the diseased heart--is not required. In some cases, a semisternotomy is sufficient, which may not sound much better but reduces recuperation time considerably. And another approach, known as heart-port surgery, requires no cracking of the chest at all but rather invades the pericardium, where the heart rests, by removing a rib or two and slipping in a fiber-optic camera, which gives the surgeon as good a view of the heart as he might have if the chest were opened up. The surgery is then performed with microsurgical instruments. Such minimally invasive techniques cut recuperation time in half, which is much easier on the patient and the finances of the health-care system. Unfortunately, the procedures themselves can still be at least as expensive--if not more so--than traditional CABG, and heart-port surgery is still considered inappropriate for some multi-vessel bypasses.
  2. Many bypass surgeries are now performed on a beating heart, meaning that the patient is not placed on the heart-lung machine, which, while eminently effective at breathing and circulating blood for the patient so that the surgeon can operate on a completely stilled heart, has been associated with postoperative blood clots and strokes and, worse, long-term neurological damage, especially memory loss. According to Cosgrove, studies of beating-heart versus heart-lung-machine or cardiopulmonary-bypass surgeries at his institution have yet to produce a definitive advantage for the more au naturel approach, but "there seems to be a slight advantage in lack of complications and recuperation time." And a study performed by a consortium of heart-treatment facilities known as the National Heart Surgery Study Group investigators found "there is an overall benefit in off pump surgery related to operative mortality and early complications--especially in patients traditionally considered high risk for CABG."

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