Heart bypass surgery and balloon angioplasty are very different procedures but some doctors are combining the two to make heart therapy easier on their patients.
Four months ago, Joan Sullivan had blocked arteries and needed two different procedures to treat them.
“I was very scared,” she says.
Doctors at the University of Maryland scheduled her for bypass surgery to reroute blood around one blocked artery and balloon angioplasty to open two other blood vessels. The procedures would have typically required two trips to the hospital but not this time.
Joan says, "They did both at the same time. And that’s what’s so unique about this.”
Joan had a "hybrid" procedure, a bypass and an angioplasty at the same time, in the same room.
Dr. Barry Reicher says the work was done in, "a room that basically is equipped both as an operating room and is a cath lab.”
There’s a big difference between the two. In a cath lab, an interventional radiologist uses non-surgical techniques.
Dr. Robert Poston says, "The more severe blockages would go to open heart surgery where you make an incision through the breast plate, open up the chest.”
For patients who have the option of the hybrid procedure, surgeons perform the bypass with a much smaller incision. Recovery time is faster.
Dr. Poston says, "By two weeks they feel pretty much back to normal. And that almost never happens in the open sternum case.”
Joan Sullivan says, "I really feel great now. Feel like my old self. Have all kinds, you know, my energy back.”
The best candidates for the one-stop hybrid procedure, like Joan, have a blockage in the major artery in front of the heart, as well as two other blockages that can be treated with stents.
Fast Facts:
About 13 million Americans have coronary artery disease.
Heart disease is the leading killer of American men and women. The condition causes about half a million deaths annually.
Two important treatments for blocked coronary arteries are angioplasty and bypass surgery.
Doctors at the University of Maryland Medical Center are now using a one-stop approach to treating some patients with coronary artery disease. The hybrid procedure involves back-to-back minimally invasive bypass surgery and angioplasty.
Supplemental Information
Coronary Artery Disease
Coronary artery disease is a narrowing of the arteries that supply blood to the heart muscle. Usually it’s caused by an accumulation of cholesterol and plaque along the inner walls of portions of the arteries. When the arteries are narrowed, a blood clot can become trapped in the clogged area. On occasion, the affected portion of the artery can become completely blocked by plaque. In either case, blood flow through the artery is impeded. The area of the heart muscle fed by the portion of the artery beyond the point of blockage is deprived of oxygen. The affected heart muscle cells die. This is a heart attack, or myocardial infarction.
According to the American Heart Association, about 13 million Americans have coronary artery disease. About 7.1 million heart attacks occur each year in the U.S. Heart disease is the leading killer of American men and women, causing about half a million deaths annually.
Heart attacks are more common in men over 45 and in women over 55. Incidence is higher in people with a personal or family history of heart disease or heart attack. Some other risk factors include smoking, high cholesterol, high blood pressure, obesity, diabetes and sedentary lifestyle.
Treating Clogged Arteries
Two important treatments for coronary artery disease are coronary artery bypass and angioplasty. In coronary artery bypass surgery, doctors use a vessel from elsewhere in the body to create a new conduit to allow blood to flow around (i.e. bypass) the area of the blockage. Surgeons may use an artery in the chest (the internal mammary artery in the chest) or a vein taken from the leg or arm. The American Heart Association reports 515,000 coronary artery bypass procedures were performed in the U.S. during 2002.
Angioplasty is a procedure in which doctors open up the clogged vessel from the inside. Traditionally, a balloon-tipped catheter is inserted through a blood vessel in the groin. Using X-rays for guidance, the catheter is slowly fed through the circulatory system to the coronary arteries. When the catheter reaches the narrowed section of the target artery, the balloon at the end of the catheter is inflated. As the balloon expands, it compresses the plaque against the wall of the artery. Sometimes surgeons use an expandable device, called a stent, which opens as the balloon inflates. The stent, which may contain a drug to reduce the risk of clotting, keeps the plaque compressed after the balloon is deflated and the catheter is withdrawn. About 657,000 angioplasties were performed in the U.S. in 2002.
Coronary artery bypass and angioplasty are usually very successful treatments to improve both blood flow to the heart muscle and the symptoms of coronary artery disease. In some places, bypass surgery can even be done through a tiny chest incision (minimally invasive direct coronary artery bypass, or MIDCAB). MIDCAB can be performed on a beating heart. Surgeons simply immobilize the portion of the heart muscle in which they need to perform the bypass, allowing the rest of the heart to beat normally. The process eliminates the need for a heart-lung bypass machine. Because of the smaller incision, patients have less post-operative pain and recovery time is faster (two to three days of hospitalization for MIDCAB versus five to six days for traditional open-heart surgery).
The Hybrid Procedure
While MIDCAB is associated with a quicker recovery, the procedure can only be used to access blockages at the front of the heart. When blocked vessels are located on the side or the back of the heart, traditional bypass surgery or angioplasty is needed. If a patient requires bypass and angioplasty, the two procedures are typically done at different times. That’s because bypass surgery is done in the operating room and angioplasty is usually done in the cardiac catheterization lab.
Doctors at the University of Maryland Medical Center are now performing MIDCAB and angioplasty in one setting. The one-step (i.e., back-to-back) approach is possible because the hospital has an operating room with a built-in catheterization lab.
First, a small incision is made in the left side of the chest. Surgeons locate the internal mammary artery and cut one end free. The cut end is then reconnected to the target artery in the heart at some point below the blockage. Blood flows directly from the internal mammary artery to the heart muscle, providing a new source of blood flow for the affected area of the heart. Once the bypass procedure is completed, surgeons begin angioplasty to open the remaining clogged vessels.
Surgeons say the one-stop heart procedure is useful for patients who have three main coronary blockages – one of which can be accessed from the front of the heart (for the MIDCAB procedure) and the other two treatable with stents. By using the hybrid procedure, patients can have all their main blockages taken care of at one time. The process avoids the need for a large open incision and use of leg veins for other bypass grafts (leg veins don’t last as long as stents in keeping the arteries open). There is a theoretical increased risk of blood clotting after placement of the stents. Surgeons are trying to find the best ways to reduce the risk of clotting without causing excessive bleeding from the bypass incision.
Web Resources
For information on heart disease and treatments:
American Heart Association Web site
National Heart, Lung and Blood Institute Web site
The Society of Thoracic Surgeons Web site
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