Weighing Your Surgical Options

I have over the last several blogs pointed out how ideas, when they come to medicine, need to be rigorously tested. I want to travel back to the original question which is “who needs coronary bypass or angioplasty to manage their coronary artery disease?” It is important to remember as I have blogged before that management of this illness is medically based. Patients need to stop smoking, manage their cholesterol with statins and diet, exercise, control diabetes and high blood pressure. At times, it becomes necessary to provide revascularization because primarily chest pain or angina is life limiting. This means that your lifestyle is hindered. This equation is different for a 45 year old man than an 85 year old man and realistic goals need to be put in place.

Angioplasty can often be easily done but does not provide a mortality benefit or a prevention of myocardial infarction. It is a treatment of symptoms that do not respond to medical management. Surgery is much the same. However, if you have left main disease or poor heart function with three vessel disease you will live longer if you have bypass surgery instead of medical management alone.

The method of surgery should be discussed with your surgeon and depends on the placement of your arteries, and the condition of the segments needed for bypass targets and other technical concerns. Also important is the surgeon’s case level and whether he or she is comfortable with the procedures required.

The concept of “minimally invasive surgery” and robotic surgery is untested at this time and is purely a variation that requires a good hard look. It was widely felt that off pump surgery would be better but that is not the case. Robots are very expensive and it remains to be seen whether the whole idea is worth the trouble and expense.

One further point about the ROOBY study is that it again proved the point about getting a complete operation. What I mean by that is that all the vessels that need to be fixed need to be fixed. Although that sounds silly, angioplasty will often target only certain arteries and “manage” the others. Off pump did a poorer job of bypassing all the vessels needed. This approach leads to worse outcomes with increased need for reoperation, angina and death. As always you should have a thorough understanding of what is wrong and what your options are. If you don’t get the answers you need continue to ask until you do.

Tags: Angioplasty, Coronary artery disease, Coronary bypass, Medical management

This entry was posted on Monday, November 30th, 2009 at 8:18 pm and is filed under Cardiac Surgery, Cholesterol, Coronary Artery Disease, Heart Failure, Myocardial Infarction. You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.