The cause of nearly 1 in 4 deaths in the U.S., coronary artery disease (CAD) kills more adults in the U.S. each year than any other disease.
Caused by the build-up of plaque in the arteries of the heart, CAD restricts—or completely blocks—the flow of oxygenated blood to the heart. The build-up of plaque typically takes years but once the opening of an artery is blocked by more than 70%, the impact makes itself known. Chest pain when exerting yourself is a common sign that something is amiss with your heart while pain when at rest is a sign that something is seriously wrong.
If caught early, CAD can often be addressed with diet, exercise, medication, and lifestyle changes. But for some, those measures may not be enough to reduce the impact of the blockage. But, as David Bull, MD, Vice President and Medical Director of the Heart and Vascular Program at Baystate Health notes, “For many of those patients, a stent may be all that’s needed to address a blockage. However, for others, especially those with blockage in multiple vessels to the heart and/or diabetes, coronary artery bypass graft surgery (a heart bypass surgery) may provide the best option to restoring the necessary blood flow to the heart.”
What is Heart Bypass Surgery?
Every year, almost 400,000 coronary artery bypass graft surgeries – heart bypass surgeries - are performed in the United States, making it the most commonly performed major surgical procedure. Referred to as CABG (pronounced cabbage) for short, the procedure effectively treats blocked heart arteries by taking healthy pieces of arteries or veins from your leg or an artery in your chest—called grafts—and using them to reroute the blood to avoid the clogged area. By attaching one end of the graft above the blockage and the other end below, CABG bypasses the blockage and restores healthy blood flow to the heart muscle. This is why it's commonly referred to as heart bypass surgery - it literally bypasses the blockage.
Bull adds, “By improving the supply of blood and oxygen to the heart, CABG works to relieve chest pain (angina), reduce the risk of heart attack, and allow an individual to return to an active lifestyle that may have been limited by a blockage. Depending up on the seriousness of an individual’s condition, some patients may undergo several CABG procedures to improve heart function.”
Aortic Disease: The Other Heart Disease
While most people are familiar with the concept of blood being blocked on its way into the heart, there’s opportunity for a different kind of trouble for blood leaving the heart in the form of aortic disease.
“Aortic disease occurs when the aorta, which carries blood from the heart to the rest of the body, becomes enlarged or dilated,” says Bull. “This enlargement is referred to as an ascending aortic aneurysm. This condition makes the aorta more susceptible to tears, ruptures and other complications.”
To prevent those issues, the Baystate Heart and Vascular team frequently performs a procedure to narrow the artery. Called an aortic aneurysm repair, this often-complicated procedure requires use of a heart-lung machine and the patient’s body temperature is cooled to prevent brain damage while either the entire artery or the affected part is replaced.
As noted, an ascending aortic aneurysm can lead to tears in the aorta referred to as aortic dissections. These same tears can also occur in patients with excessive high blood pressure or certain hereditary conditions. Regardless of the cause, aortic dissection is a very serious condition as any blood that rushes through the tear, which occurs in the inner layer of the aorta, can cause the aorta to split. If not treated quickly, a patient can die within hours.
Bull says, “Repairing an aortic dissection is a very intricate surgery involving repairing the tear in the aorta or replacing a portion of the aorta. Often, the procedure requires stopping the heart to complete the work.”
He adds, “In some patients, even surgical repair may not be feasible due to extreme calcifications and other issues. For those individuals, there are new solutions on the horizon here at Baystate. For example, an Endo-Bentall prosthesis allows for a graft to be placed directly in the aorta to correct the aneurysm or dissection. It eliminates the need for a heart-lung machine or even open surgery. The lack of an invasive procedure allows for a shortened hospital stay and quicker time to recovery than would be experienced with more traditional surgeries.”
End-Stage Heart Failure: Not Always the End Thanks to New Technology
For patients with persistent, compromised heart function due to repeated heart attacks, inherited conditions, or other issues that lead to a weakened heart muscle, Bull notes there are new surgical advancements that offer hope. Specifically, implanted mechanical surgical devices provide short- or long-term circulatory support to the heart. Because these devices are most commonly used to support the left ventricle of the heart, they’re commonly referred to as LVADs (left ventricle assist device).
According to Bull, “The current battery-operated devices are so small that they do not require opening the sternum to be implanted. LVADs were originally used as a ‘bridge’ device for patients awaiting a heart transplant. The LVAD would keep their heart working until a transplant became available. More recently, the LVAD is being considered a long-term solution to heart failure. In fact, patients with LVAD are living 14-15 years after implementation whereas heart transplant patients who live 8 years post-surgery are considered a success.”
Stroke: The Inherent Risk of Cardiac Surgery
All types of cardiac surgery carry the risk of stroke during or after surgery. In fact, stroke risk for specific procedures tracks this way:
- 1% for coronary artery bypass or valve repair alone
- 2-3% if those procedures are combined
- 3-9% for aortic surgeries
- 10%+ for those who develop atrial fibrillation (AFib) post-surgery
Given the risk, Baystate Health screens all cardiac surgery patients prior to procedure for the following risk factors:
- Age 65 years or older
- High blood pressure
- High cholesterol
- Type 2 diabetes
- Smoking
- Heart failure
- Kidney disease
- Atrial fibrillation (AFib)
- Prior history of stroke or transient ischemic attack (TIA)
Patients who are cleared for surgery are closely monitored during the procedure to look for any potential clots or plaque using the following:
- Transesophageal echocardiogram (an ultrasound of the heart)
- Epiaortic ultrasound of the ascending aorta (an ultrasound of the aorta specifically)
- Cerebral oximetry (measuring the oxygen level in the brain)
- Blood pressure control
- Closely monitored blood loss, including transfusion if needed
For patients deemed a high risk for stroke, the surgeon and anesthesiologist will work together to make sure a stroke is recognized quickly post-surgery. This includes using a fast-track anesthesia protocol that brings the patient around quicker so they can be assessed as soon as possible. Once alert, a complete neurological exam is performed while a stroke team stands ready to assist. If a stroke is suspected, a head CT and CT angiography (a scan of the blood vessels) is performed immediately so that corrective measures can be taken, including immediate transfer to the ICU, restoration of blood flow to the brain, and any appropriate intervention, including surgery, to reverse signs of an evolving stroke.
The Future of Cardiovascular Care at Baystate
In the past several decades, tremendous strides have been made in improving the efficacy of cardiac surgeries and providing patients with longer lives and better quality of life. Baystate Health is actively involved in improving the world of cardiac care options through participation in clinical trials and the development of state-of-the-art devices and implants. New non-surgical cardiac care options are also helping patients spend less time in the hospital and return to their everyday activities faster after treatment.
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