The Future of Your Heart Attack
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.
- 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
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."
- 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.
- 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."