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In this article:
The main goal of repairing a heart
affected by coronary
artery disease (CAD) is revascularization
—that is, improvement of blood flow to the heart. Better flow
means more of the oxygen-rich
blood needed as fuel for energy reaches the heart.
Your doctor might tell you that a hospital procedure is necessary
for several reasons. One is that your angina
medications may not have totally controlled your chest pain or discomfort.
Or, perhaps you may not have been able to tolerate your medicines.
Some doctors believe that non-surgical and surgical procedures may
be a better first choice than medications. Last, if you have had
a sudden onset of unstable
angina or have had a heart attack,
your doctor might feel that surgery is the best way to save your
life. (See When Angina Gets Worse for more about unstable angina
and heart attacks.)
This LifeHeart.com article explains different types of heart procedures, how
they may help improve your attacks of angina pain or discomfort,
as well as possible unwanted effects. Be sure to ask your doctor
for specific information about your particular procedure.
Balloon angioplasty (PTCA)
PTCA, short for percutaneous
transluminal coronary angioplasty, is a non-surgical procedure
that uses a balloon to open a vessel
clogged with plaque.
A cardiologist
makes a small surgical cut (incision) in the arm or leg. Next, he
or she inserts a long tube (catheter) through the incision into
an artery.
Using a television monitor as a guide, the cardiologist routes the
tube to the heart. A balloon is at the far tip of the catheter.
When the cardiologist sees that the balloon has reached the area
where plaque has narrowed the passageway, the balloon is inflated.
This presses the plaque against the artery wall and opens up the
lumen
of the artery to more normal blood flow. The heart can then receive
more of the oxygen-rich blood it needs.
One benefit of PTCA is a short hospital stay, sometimes only for three or four
days. You'll also be able to return to your usual activities relatively
quickly.
PTCA isn't for everyone. Some people, especially women, have smaller
vessels that may make insertion of the catheter difficult. PTCAs
may also cause problems in some people. One possible risk is the
re-clogging of the blocked artery. This is usually referred to as
restenosis.
Between three and four in every 10 patients who get a PTCA may have
a restenosis within six months of the procedure.1 Sometimes, the
PTCA may need to be repeated.
A sudden complete closure of the artery by a blood clot is another risk. Specific
medications have been developed to help prevent this. But if this
happens, or if another serious heart problem occurs during the PTCA,
then emergency open heart surgery may be necessary.
Angioplasty and stents (PCI)
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The guidewire and balloons are withdrawn. The stent remains in place to help maintain an open lumen. Click here to enlarge and go to the image library. |
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Stents
have been developed to decrease the chance of restenosis after PTCA.
Percutaneous
coronary intervention (PCI) is a newer term that combines both
PTCA and stents.
A stent is a type of wire mesh that fits within the artery. It
is inserted during the PTCA procedure and usually covers the balloon.
When the balloon opens up to press the plaque against the artery
wall, the stent opens up, too. Once the balloon is deflated and
pulled out of the artery, the stent stays open and keeps the plaque
in place. Only about two to three in 102,3 patients may develop
restenosis of the coronary
artery after a stent is placed. Most PTCA procedures use stents
now, so your chance of having a repeat procedure may be reduced.
Stents coated with certain drugs may reduce this risk even further.
Read more in Potential Therapies.
Bypass surgeries
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Coronary artery bypass graft (CABG)
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Blood vessels commonly used in coronary artery bypass graft surgery. Click here to enlarge and go to the image library. |
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A coronary
artery bypass graft is a type of open heart surgery often abbreviated
as CABG (pronounced "cabbage") or CAB. Simply put, a heart surgeon
removes a section of blood vessel from another part of the body,
usually the leg or breast, and uses it in the heart to create a
special detour around the clogged artery. The heart can then receive
all the oxygen-rich blood it requires.
CABG is major surgery. Your heart surgeon will need to cut your
breastbone in half to reach the heart and have enough space to
work in. (Some newer procedures avoid this. See MID-CAB below.)
Also, the surgeon must make a separate incision to obtain the
section of vessel that will be attached to the heart.
You may also need to go on a heart-lung (cardiopulmonary bypass)
machine. These machines take over the function of your heart and
lungs so that your surgeon can work easily on your non-beating
heart. You may be in the hospital for about five days, and it
may take up to six weeks to recover.
Open heart surgery may also cause some complications. Some people
may get an infection after surgery and need an antibiotic (although
antibiotics given at the start of surgery and just after can help
prevent infections). Also, some people may have difficulty concentrating
after CABG because of decreased blood flow to the brain during
the procedure.4
Others may be at risk for a stroke. Occlusion,
or closing up of the transplanted vessel, may happen as well.
Depending on the type of vessel used, occlusion occurs in anywhere
from one to four in 10 patients.1
Angina pain or discomfort may later return and you may have to
change your daily activities to avoid pain.
Is anyone ever too old for heart surgery? Not really. Though
the risks of surgery are high, a recent study has shown that open
heart surgery can be done almost as safely in people 80 years
of age and older as in younger people.5
Off-pump coronary artery bypass graft
(OP-CAB)
Today, open heart surgery is a risky and traumatic procedure
that includes opening the chest and putting a patient on a heart-lung
machine so a surgeon can operate on a non-beating heart. Cardiologists
are working hard to find ways to make this kind of procedure easier
on the body. Some surgeons have started to use a technique, called
off-pump
coronary artery bypass graft (OP-CAB), that doesn't use a
heart-lung machine. As with a traditional CABG operation, surgeons
still need to split the breastbone during an OP-CAB. But instead
of using a heart-lung machine, which stops the heart from beating,
surgeons use a mechanical device called a stabilizer to restrict
heart movement in the small area where they will connect a new
blood vessel taken from the leg or breast to the heart to restore
healthy blood flow. During OP-CAB, the heart continues to beat,
except in the isolated area. OP-CAB seems to result in shorter
hospital stays and fewer complications after surgery.6
Many surgeons also prefer off-pump surgery because use of a heart-lung
machine during bypass surgery has been linked to decline in the
ability to concentrate after surgery because of decreased blood
flow during the procedure. Surgeons hope that by avoiding use
of the bypass machine, the risk for concentration problems may
be reduced.
However, a new study in the Journal of the American Medical
Association reveals that patients who had an off-pump procedure
had about as much decline in mental function one year after surgery
as those who underwent a traditional, on-pump open heart surgery.
Three months after surgery, the off-pump group seemed to fare
better: 21% showed decline in mental function, compared to 29%
of the on-pump group. But by 12 months, the gap narrowed: 30.8%
of the off-pump group showed decline, compared with 33.6 % of
the on-pump group—an insignificant difference. Additional research
is needed to confirm these results. 7
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Minimally invasive direct coronary
artery bypass graft (MID-CAB)
Minimally
invasive direct coronary artery bypass graft (MID-CAB) is
another new kind of open heart surgery that is less invasive than
traditional open heart surgery. The breastbone is not cut open;
instead, a surgeon makes a small, three-inch incision just below
the left breast. Using video monitors to guide the operation,
the surgeon makes a detour vessel (a vessel that is attached to
the heart to bypass a blocked artery) using an artery from the
chest wall. Patients who undergo a MID-CAB may have less risk
of experiencing complications after the procedure when compared
to traditional open heart surgery. Your doctor can provide you
with more information.
People who have a traditional open heart surgery can take weeks
to recover. People who have a MID-CAB can recover in about one
week.
Your life after surgery
Just like medications, surgery may help prevent a deadly heart
attack. But angina pain or discomfort may return even after surgery.
In a recent study of patients who had undergone a PCI, the most
important determinants of quality of life were the number of angina
attacks patients experienced and how much those attacks limited
their ability to perform their usual activities.8
You also may need to take medications for life to help keep your
CAD under control. Plus, if you have concentration or memory problems
after surgery, you may still be kept from enjoying your daily routine,
even though surgery may have added years to your life.
Having a good quality of life is another treatment goal you and
your doctor should discuss. To learn more, visit the Quality of
Life section of LifeHeart.com.
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Pushing yourself beyond your limits is the only
way for angina patients to gauge how much exercise
they can perform safely. True or False?
Click here. |
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Sources
1. "American College of Cardiology/American
Heart Association/American College of Physicians/American Society
of Internal Medicine Guidelines for the Management of Patients with
Chronic Stable Angina." Journal of the American College of Cardiology,
1999, Vol. 33, No. 7. 2092-2197.
PubMed
2. Serruys, P.W., P. de Jaegere,
et al. "A Comparison of Balloon-Expandable-Stent Implantation with
Balloon Angioplasty in Patients with Coronary Artery Disease." New
England Journal of Medicine, 1994, Vol. 331, Number 8. 489-495.
PubMed
3. Fischman, D.L., M.T. Leon,
et al. "A Randomized Comparison of Coronary-Stent Placement and
Balloon Angioplasty in the Treatment of Coronary Artery Disease."
New England Journal of Medicine, 1994, Vol. 331, Number 8.
496-501.
PubMed
4. Newman, M.F., J.L. Kirchner,
et al. "Longitudinal Assessment of Neurocognitive Function After
Coronary-Artery Bypass Surgery." New England Journal of Medicine,
2001, Vol. 344, Number 6. 395-402.
PubMed
5. Avery, G.J., S.J. Ley, et
al. "Cardiac Surgery in the Octogenarian: Evaluation of Risk, Cost,
and Outcome." Annals of Thoracic Surgery, 2001, Vol. 71,
Number 2. 591-596.
PubMed
6. Lee, J.H., K. Abdelhady,
et al. "Clinical Outcomes and Resource Usage in 100 Consecutive
Patients after Off-Pump Coronary Bypass Procedures." Surgery,
2000, Vol. 128, Number 4. 548-555.
PubMed
7. Van Dijk, D., E.W.L. Jansen,
et al. "Cognitive outcome after off-pump and on-pump coronary artery
bypass graft surgery: a randomized trial." Journal of the American
Medical Association, 2002, 287. 1405-1412.
PubMed
8. Green, D.L., P.G. Jones,
et al. "The Relationship Between Angina Frequency and Patients'
Quality of Life." American College of Cardiology Annual Meeting,
2002. Abstract #1168-170.
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