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So you think you need... bypass surgery

MagazineJune 2013 (Vol. 24 Issue 3)So you think you need... bypass surgery

Here's one operation you might want to bypass and opt for more conservative treatment

Here's one operation you might want to bypass and opt for more conservative treatment.

The operation was successful, but the patient died. That's how bypass surgery began in 1962, when renowned American cardiac surgeon David Sabiston, chairman of the department of surgery at Duke University School of Medicine, grafted a vein taken from the patient's leg and attached it to the ascending aorta to bypass the blocked right coronary artery during open-heart surgery.

Sabiston was gratified when the graft took-more gratified than his patient, that is, who died just three days later of what was put down to'unrelated complications'.

Despite such inauspicious beginnings, some 50 years later heart bypass surgery- or coronary artery bypass graft (CABG) as doctors call it-has become the most frequently performed of all surgical operations, with some 450,000 carried out every year in the US alone and 28,000 in the UK.Around10percentofallheartpatients will eventually undergo a coronary bypass, especially if they have one or more heart arteries that are either blocked or severely narrowed.

There's no doubt that it's miracle surgery for some, but besides being one of the most common reasons for patients to go under the knife, the bypass is also one of the most unnecessary of operations. Heart surgeons have suspected this since the 1970s, when several major studies revealed that bypass surgery did not improve survival except among patients with severe coronary disease, especially of the left ventricle.

How it works

During the operation the surgeon removes veins from the patient's leg, forearm or chest, and grafts these onto a healthy portion of one of the main coronary arteries to get around the portion that is blocked. The traditional or 'on-pump' method is carried out while the heart is stopped and the patient and his blood supply are attached to a pump, which oxygenates it and pumps it back into the patient.

Because of the high potential for things to go wrong, surgeons increasingly opt for an 'off-pump' technique, also known as 'beating-heart bypass surgery', where the heart is kept going and stabilized through the use of special equipment-a procedure that surgeons maintain is far safer.

What doctors tell you

Since 1978, balloon angioplasty has superseded bypass surgery as the less-invasive way to prevent a heart attack in patients with clogged coronary arteries. The procedure involves threading a tiny balloon through blocked arteries and inflating it to clear them, usually by pressing the fatty plaques against the arterial wall and inserting a tiny piece of metal scaffolding called a 'stent' to keep the artery open.

Doctors tend to advise bypass rather than angioplasty if:

-all three arteries of the heart are blocked or narrowed (two arteries if you have diabetes)

-your left main heart artery in particular is very narrow

-you need to repair or replace a heart valve anyway

-your heart isn't pumping efficiently.

The received wisdom has been that angioplasty is the safer option-that is until a recent US National Institutes of Heath (NIH) study analyzing the records of around 189,000 patients found that, after four years, the CABG group (or 'cabbages', as many doctors refer to them) had a 21 per cent lower rate of mortality compared with angioplasty.

What doctors don't tell you

-Both procedures carry a high mortality rate. In absolute terms the differences between the two operations are small; in the NIH study, 16 per cent of CABG patients died during the four years compared with 21 per cent of angioplasty patients. When all major studies comparing the two ops are combined, there's no significant difference between the two procedures when it comes to deaths and ill effects.

-The 'low mortality' of CABG isn't all that low. According to one review of all major studies, three out of every 100 people who have the op die, and up to one in four suffers from complications.

What else doctors don't tell you

The benefits of bypass surgery are unpredictable and can even bring on the very problems it was supposed to prevent.

-It may not make your heart work better. A review of 37 studies of bypass surgery concluded that the patient's heart function improves in only one-third to a half of all cases. The rest had basically the same heart function they had before the operation.

-Your heart may develop abnormal heart rhythms. More than a quarter of all patients suffer atrial fibrillation (unstable heart rhythms) after their bypass surgery, even when given intravenous magnesium, supposed to help prevent it.

-You could suffer angina. Although bypass surgery is supposed to eradicate the condition, usually caused by arterial obstructions, around one in five bypass patients suffers heart pain even after surgery.

-You could suffer stroke. One in six CABG patients have a stroke or other effects to the brain, including brain death.

-You could experience mental decline-'pumphead', as doctors call it, or 'postperfusion syndrome' as it's formally known. After a year, roughly a third of all CABG patients suffer some deterioration of their mental faculties, mostly because of the high risk that thousands of microscopic blood clots get dislodged and find their way to the brain.

-You could develop gut problems. As one in 20 bypass patients do.

-There's a good chance you'll have future breathing difficulties. More than half of CABG patients complain of chest pain and breathing difficulties after five years, increasing to nearly three-quarters of patients after 15 years.

-The off-pump procedure could cause permanent brain damage. And has six times the risk of grafts not taking and closing up.

-You could die within a year as do more than 6 per cent, or one in every 17, patients.

-You're likely to need a repeat op to bypass the original bypass. Your chances of needing a second surgery increase by around 5 per cent every year. Cardiologists acknowledge that grafted vessels close up within 10 years in 40 per cent of patients, while other arteries close up in the remaining 60 per cent.

The bottom line: Most bypass patients will need further surgery within a decade to repair work already done or allow first-time work on different vessels.

What to do instead

Perversely, those who do nothing or who control the problem with drugs or diet can fare just as well, if not better, than those who have gone through the trauma of a procedure that involves cutting open the ribcage and stopping the heart for several hours.

"The common practice of rushing patients in for emergency or urgent surgery because of a severely narrowed coronary artery is completely unnecessary, and needlessly frightens the patient and his family," says Dr Howard Wayne of the Noninvasive Heart Center in San Diego, California.

This view is supported by several studies showing that the chances of survival following a mild heart attack are higher if the hospital does not immediately operate, but adopts a conservative approach instead.

In one study by the US Veterans' Administration, more than three times as many bypass patients died compared with those managed through 'watchful waiting'. Three years later, nearly a quarter fewer patients had died through conservative management than with bypass surgery.

However, doing nothing doesn't mean tucking into burgers and fries. It means a radical change of lifestyle, especially your diet, and of any other factors that most likely brought on the heart disease in the first place.

What to do to help yourself

-Allow the body to self-repair. In three-quarters of cases, a heart with blockages of the main vessels will engineer the growth of new blood vessels to form its own natural bypass of the obstructed arteries.

The self-healing heart

The best medicine may be to do nothing-at first. New evidence shows that when left to its own devices, a heart with obstructions in the main vessels somehow has the exquisite intelligence to know that it isn't getting enough oxygen and so will embark on its own cure.

In three-quarters of cases, the heart will engineer the growth of new blood vessels to form its own natural bypass of the blocked arteries. These 'collateral' blood vessels keep blood flowing to the heart when the main vessels don't work properly.

Within three to six months, those patients who do absolutely nothing at all will experience relief of their chest pain.

Collateral vessels tend to grow when arterial narrowing and blockages arise slowly over time. A vessel that is only slightly narrowed, but then suddenly blocks completely, is likely to cause a heart attack, and such an event the body can't prevent.

Nevertheless, these collateral vessels vanish in a patient given bypass surgery. If the bypass doesn't take, these patients are then in more danger than if they had kept their temporary 'detour' vessels' intact.

This suggests that the heart has its own self-healing mechanism, which is interrupted when doctors rush in too quickly after a patient has suffered an acute heart attack. In one study by the US Veterans' Administration, more than three times as many bypass patients died as those managed through 'watchful waiting'. Three years later, nearly a quarter fewer patients had died through conservative management than bypass.

-Choose heart drugs for blocked vessels over the knife. Patients with angina or heart attack who are managed invasively with angioplasty or bypass surgery have twice the risk of a heart attack and 1.7 times the risk of bleeding as those simply given drugs, according to a five-study review.

-Clean up your diet. Increasingly, heart disease is being linked to our refined, processed, high-sugar diet. Eat whole, unprocessed, organic foods grown locally and in season and cooked by traditional methods, and stick to low glycaemic-index carbs. Also ditch 'plastic butter'-all hydrogenated margarine and other hydrogenated oils or high-fructose corn syrup.

-Go Mediterranean with a diet rich in fruits and vegetables and olive oil, with meat as a condiment rather than the centrepiece of meals, and plenty of fish. This diet, when followed by heart patients with no other intervention, yielded results more than twice as good as the very best results achieved by medicine with cholesterol-lowering drugs. New heart attacks and death were decreased by 70 per cent among heart-attack patients following the Mediterranean diet compared with those following the usual 'prudent' diet generally prescribed to cardiac patients.

-The X-factor: Higher intake of omega-3 fatty acids from fish and flaxseed oils, lower intakes of omega-6 fatty acids from corn, safflower and soybean oils, plus higher intake of the antioxidant vitamins C and E.

-Take vitamin C.This vitamin reduces the amount of high-sensitivity C-reactive protein in the body, a marker of inflammation and one of the main causes of cardiovascular disease. Heart patients are twice as likely to die within a year if their vitamin C levels are low. Even eating your five-a-day portions of fruit and veg provides enough vitamin C to reduce your risk of fatal heart failure by 2.4 times.

Dosage: 1-3 g/day or more with the guidance of a trained nutritional therapist.

-Suplement with other antioxidants. Heart patients improve with supplements of antioxidants, B vitamins, coenzyme Q10 and other supplements.

Your heart-healthy supplements

Besides a generous supply of vitamin C, work with an experienced qualified practitioner to determine how much of the following you should take.

-B vitamins: B6 protects your heart against further damage and thiamine (B1) can help your heart's pumping function.

Dosage: 50-100 mg of vitamin B6 and 50 mg of thiamine

-l-Carnitine can help stabilize the heart after a heart attack. Dosage: 250-750 mg/day

-Vitamin E protects the heart when taken before coronary bypass surgery and with high-dose vitamin C.

Dosage: 400 IU of alpha-tocopherol

-Seleniumcan help protect heart tissue against oxidative stress. Dosage: Up to 200 mcg/day of selenium and 5000 IU of vitamin A.

-Coenzyme Q10 may prevent heartbeat irregularities and prevent cell damage to the heart during a heart attack. Choose a formula containing ubiquinol, which is better absorbed.

Dosage: 60-100 mg/day (or higher with supervision)

-Omega-3 fatty acids are known to be heart-protective.

Dosage: 1000-1500 mg/day of fish oil

-Magnesium lowers blood pressure.

Dosage: Between 200-600 mg/day.

-Consider chelation therapy. Used by many doctors in the US and UK, this therapy involves a patient being given intravenous infusions of disodium EDTA (ethylenediaminetetraacetic acid, an acidic form of a sodium salt) along with vitamins C and B, electrolytes, procaine and heparin to chemically 'grab' or chelate the fatty deposits on arterial walls. Chelation was given a recent cautious thumbs up by the Columbia University College of Cardiology after it was shown to modestly reduce the chances of a repeat heart attack.

-Meditate. This has been shown to help heart patients lower their risk of reduced blood supply to the heart due to blood vessel narrowing and fatal heart attack.

-Get needled. Patients receiving acupuncture are able to significantly increase the work capacity of their hearts. Acupuncture also increases heart-healthy omega-3 fatty-acid concentrations.

-Go ginkgo.Ginkgo biloba reduces pain in heart patients, helping them walk over longer distances, and also 'thins' the blood of patients with 'hardening of the arteries'.

-Visit a herbalist who may prescribe:

-bromelain, derived from pineapple, which can help to reduce angina, as may also hawt horn extract (Crataegus pinnatifida)

-ginger, a known blood-thinner that also inhibits the development of atherosclerosis (fatty deposits in blood vessel walls)

-Terminalia arjuna, which can reduce the symptoms and signs of heart failure.

-Look to the East. A number of Chinese herbs exert profound effects on the heart. One, called Andrographis paniculata Nees, has proved useful for preventing recurrent clogging of the arteries after angioplasty.

-Rediscover your passions.Change your job or any other parts of your life that you aren't happy with.

-Get connected. This may be the best drug of all.

Dying of a broken heart

California heart expert Dr Dean Ornish has discovered an extraordinary statistic: all the usual risk factors for heart disease-smoking, obesity, sedentary lifestyle and a high-fat diet-only account for half of all heart disease. In Ornish's research, no risk factor appears more dangerous than simple isolation-from other people, from our own feelings and from a higher power.

In a study carried out in San Francisco and another in Eastern Finland, of the nearly 20,000 people observed for up to nine years, those who were lonely and socially isolated were two to three times more likely to die of heart disease and other causes than those who felt connected to others. These results were discovered to be independent of risk factors like high cholesterol levels and high blood pressure, smoking, diet and family history.

Studies of other populations, such as Japanese-Americans, have also demonstrated that social networks and social support protect them against heart disease-regardless of whether they smoke or have high blood pressure. Whatever the Japanese ate-whether tofu and sushi or a Big Mac-had no bearing whatsoever on their propensity to heart disease so long as they maintained strong social ties.


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