Heart Surgery
The Truth About Treatment Options in Ischaemic Heart Disease
Heart attacks are the 2nd commonest cause of death in India today. The disconcerting fact is that India is often now referred to as the heart disease capital of the world. Heart disease affects Indians at least a decade earlier than in the west. What is causing this phenomenon
Coronary artery disease-which is the cause of heart attacks, is known
as a lifestyle disease. It is the unhealthy life style that we lead
today that is responsible for this increase in addition to the high
incidence of diabetes and a genetic predisposition.
When the arteries that supply oxygen rich blood to the muscles of the
heart are blocked one gets either a heart attack ( due to a sudden
blockage ) or angina ( chest pain on exercise or at rest ) .
The treatment of a heart attack is of course an emergency
hospitalization with administration of clot dissolving medicines and an
opening of the blockage by an angioplasty if possible. Rarely, an
emergency operation to open this blockage by way of a bypass surgery is
required.
If a person comes with complaints of chest pain , or breathlessness or
throat constriction on walking he needs to undergo the following basic
investigations to determine the cause of these complaints.
1) Resting ECG
2) Stress Test ( ECG during exercise)
3) 2 D echo
If these investigations are normal, the chest pain is likely to be not
related to the heart and alternative causes ( acidity , lung problems or
indigestion ) may have to be looked at.
If the above investigations are abnormal, further investigations in
the form of either a CT angiography or a conventional angiography is
required.
A CT angiogram is done by a doctor called a radiologist by taking a CT
scan of the heart on a special very fast CT scanning machine that
requires the patient to hold his breath for 4-5 secs only. The entire
procedure takes about 10 mins and the patient does not require to be
admitted to a hospital for this investigation. This investigation
however has limitations as it is not a 100 % accurate and cannot be
performed in patients who have calcium deposits in their arteries. It is
not a very specific test and if it indicates the presence of blocks a
conventional angiogram is necessary.
A conventional coronary angiogram is the “Gold standard” investigation
for coronary artery disease. It requires admission to a hospital for a
day and is performed by a doctor called a cardiologist by puncturing an
artery in the groin or the hand to insert a tube ( catheter) into the
arteries of the heart . A special dye that is visible on X-rays is then
injected into the arteries of the heart to determine the presence of any
blockages. If blockages are present the cardiologist may recommend
either of the following
1) Angiolpasty with stents
2) Coronary artery bypass grafting ( bypass surgery)
3) Treatment with medicines only if the blockages are not very important!
If an angioplasty with stents is recommended, it can be done at the same time as the angiography if the patient and his relatives are ready both mentally and financially for the procedure. Contrary to popular belief , this is not an operation and is done through a catheter in the groin by a cardiologist. It does not involve any cut on the chest and thus is a very attractive procedure. However, this procedure is either not feasible or not advisable in some patients . All patients who are advised to undergo an angioplasty should ask the cardiologist the following questions before agreeing to undergo the procedure:
1) Is it a safe procedure
2) Is there any chance of requiring an emergency operation
3) How long will the stents stay open or how soon are they likely to get blocked
4) How much is the entire procedure likely to cost – are the best stents being used
Sometimes , it pays to get more than one opinion on the subject as
medicine is not mathematics and two cardiologists or a cardiac surgeon
may differ on their recommendations on the same angiogram. If the
patient has diabetes , angioplasty may not have good results and the
patient may be recommended to undergo a bypass.
A coronary bypass grafting is an operation performed by a cardiac
surgeon. It involves taking a cut on the front of the chest (
breastbone) and exposing the heart . The blockages are then identified
in the arteries after careful correlation with the angiogram and a
bypass is performed. A bypass involves construction of an alternative
pathway for the blood to pass to the heart muscles. It is much like the
construction of a flyover to bypass a crowded area on the road so that
traffic can move without an obstruction. Normally , an artery is taken
from the chest ( mammary ) or from the hand ( radial ) and transplanted
to the artery on the heart. This is usually done while the heart
continues to beat (beating heart surgery), but sometimes the surgeon
needs to stop the circulation with the help of a heart lung machine to
perform the operation. A total arterial bypass (bypass using only
arteries ) is expected to last for a period of 10-15 years (depending on
lifestyles, diabetes control, cholesterol levels etc ). A bypass with
one artery and the rest as veins can last from 7-12 years! Thereafter a
2nd bypass ( redo bypass) can be performed quite easily. The recovery
period is different for different individuals but on an average is about
6-8 weeks
A lot is being said about a minimally invasive bypass. This involves
taking small cuts on the chest wall through which the entire operation
can be performed. At the moment, this is limited to performing only one
or two grafts. But if you have a robot and cost is no consideration,
more grafts and more difficult operations can be performed through these
small incisions . The cost of a robotic minimally invasive surgery can
be upwards of Rs.10 lacs at current estimates and hence are not widely
performed. Today, most of the bypasses performed involve multiple grafts
( 3 –5) which are not realistically possible through minimally invasive
small incisions.
