Heart Health: Assessing options for managing a heart condition

  • Dr. Kelly M. Wanamaker Courtesy photo

Published: 3/3/2020 8:43:47 AM

It is a given that any patient facing the possibility of a surgical procedure would prefer an approach that involves the least amount of cutting and the least amount of recovery time.

Increasingly, cardiac patients today needing management beyond medication therapy for their heart condition have a growing number of such options both in terms of diagnosis and treatment.

It is estimated that nearly 1 million percutaneous coronary intervention procedures are now done annually by interventional cardiologists in the United States.

These procedures, which do not involve cutting into the chest, are done to treat coronary artery disease through the insertion of interventional catheters and guidewires into a blood vessel to open up arteries that have become narrowed by disease.

A balloon at the tip of the catheter is inflated at the point of the blockage to push aside the buildup of a substance called plaque and to allow the permanent placement of a stent if needed to ensure the artery remains open to supply blood to the heart after the balloon is deflated and removed.

However, thousands of open-heart surgeries continue to be done annually in the United States.

The most common open-heart procedure is what, among cardiac surgeons, is often referred to as “CABG,” pronounced cabbage, that is, Coronary Artery Bypass Grafting.

CABG is the surgical answer to blocked arteries. Rather than the interventional approach of balloon and stent, a harvested vein or artery is grafted onto the heart to form a bypass around the narrowed artery.

This is done for various reasons: failed stents, multivessel disease, unfavorable anatomy, to name a few. We know that bypass surgery for diabetics, for example, offers improved long-term survival benefits that supersede stents.

Other top open-heart surgeries involve replacement of the aortic valve that facilitates the flow of oxygen-rich blood from the heart to the rest of the body; repair of the mitral valve that controls blood flow between the two chambers on the left side of the heart and operations for aortic aneurysms that are abnormal bulges in the wall of the body’s major blood vessel.

Sometimes, the aortic valve can be replaced without open-heart surgery through a minimally-invasive procedure known as Transcatheter Aortic Valve Replacement, or TAVR, in which the replacement valve is inserted through the use of a catheter and balloon.

TAVR has typically been done on older patients — many in their 80s and 90s — who particularly benefit from shorter hospital stays and recovery time in addition to other patients who may also be considered at too high a risk for surgery.

Surgical Aortic Valve Replacement, or SAVR, is usually done on younger patients considered at low to medium risk for open-heart surgery or who may also need CABG at the same time.

This approach is a better option should any additional surgery be needed in the future, since we are still uncertain of long-term durability of the TAVR valves.

Tissue replacement valves, created from animal donor pericardium, are often popular because they don’t require the use of long-term medication to prevent blood clots and can last between 10 and 20 years.

There is always discussion of less-invasive surgery as patients would like to avoid open-heart surgery, but sometimes such surgery is the best option for a patient’s long-term survival and that is how I counsel patients as a cardiac surgeon.

Being placed on a machine that takes over the work of the heart and lungs during surgery can be unsettling for a patient to consider, but both technological as well as clinical advances today have improved both how open-heart surgery is done and how patients recover.

Open-heart surgery patients usually are in intensive care for a day and hospitalized for three to five days — much shorter times compared to when I started in this field as a registered nurse taking care of such patients.

The importance of cardiac rehabilitation programs, which today often include nutritional and other counseling, is also much better understood and help with better long-term outcomes for patients.

Dr. Kelly M. Wanamaker, MD, FACS is a board certified cardiac surgeon with Baystate Medical Center’s Heart and Vascular Program.

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