Surgical treatments for heart disease
May 11, 1999
By Stephanie Slon
(WebMD) -- Heart disease kills almost 12 times as many American women as breast cancer does. Despite this sobering statistic, the risk of coronary artery disease in women goes undetected and untreated far too often. Like men, women begin the battle against heart disease with lifestyle changes followed by a battery of medications. When a heart attack seems imminent despite those efforts, the answer for both sexes often lies in surgery.
Coronary artery bypass graft (CABG) is the tried and true operation to restore a healthy flow of blood to the heart muscle. The surgeon borrows a blood vessel from another part of the body to build a new passage to the heart. Bypass surgery has been performed for 25 years, and the success rate is up to 98 percent; it's a safe procedure in the hands of an experienced surgeon. On the downside, it involves cutting through the chest bone -- a wound that takes two months or more to heal.
The other established surgical method for treating coronary artery disease is percutaneous transluminal coronary angioplasty (PTCA), better known as balloon angioplasty. This surgery involves snaking a thin, balloon-tipped catheter into the arteries that surround the heart muscle. The balloon is inflated at the point of blockage, compressing the fatty deposits against the arterial wall. This allows blood to once again flow freely through the vessel. PTCA requires only a small incision in the leg, where the catheter enters the body. Thus the procedure is far less traumatic than CABG. General anesthesia isn't necessary, and the patient leaves the hospital after a few days. Unfortunately, almost a third of the time coronary arteries clog again within six months, requiring another angioplasty or a bypass operation.
The medical community is embroiled in a controversy over whether bypass surgery and angioplasty are as safe and effective in women as in men. Timothy J. Gardner, MD, chief of cardiothoracic surgery at the University of Pennsylvania and chairman of the American Heart Association's surgical council, takes this stand: "I don't think there are any significant gender-related issues that would determine whether a woman patient should have bypass surgery or angioplasty. What you want to make sure is that the advice you're getting on which procedure to have is appropriate. You and your doctor can then determine your risk based on your age and other medical factors."
Other surgical treatments for heart disease range from variations on CABG and angioplasty to techniques that seem as if they came out of "Star Wars." A promising new surgical procedure called minimally invasive direct coronary artery bypass (MIDCAB) is conducted through a small chest incision over the sick arteries. MIDCAB is performed while the heart is beating, eliminating the need for a heart-lung machine. However, limitations on the type and location of coronary blockages that can be reached make it appropriate for only about 10 percent of CABG patients.
The biggest breakthrough in the world of angioplasty is a device called a stent -- a wire-mesh tube placed in the artery after balloon angioplasty to prevent the vessel from closing again. Half of all angioplasty procedures now use a stent, and Dr. Gardner predicts a rise to 75 percent within the next few years.
On the more experimental side of angioplasty, cardiologists are testing a catheter-guided laser device that would vaporize fatty deposits from the walls of the arteries. The complication rate is still quite high, so this procedure isn't in general use.
Lasers are also used in a technique called transmyocardial revascularization (TMR). For patients who aren't good candidates for CABG or who have had poor luck with angioplasty, some doctors are attempting to increase the heart's blood supply by laser-drilling channels directly in the heart-muscle wall. So far the technique has brought relief to many longtime angina sufferers. Because the holes eventually heal over, though, it is unclear whether this procedure halts the progression of heart damage.
Although the future of TMR and other experimental techniques remains hazy, it's a safe bet that there will be more, newer and better heart-disease treatments for both women and men in the years to come.
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