Last year, George Fenn, an economist and consultant in Cambridge, Massachusetts, was running out of steam and didn’t know why. At 54, Fenn, an avid runner, regularly logged about 20 miles a week. But he couldn’t maintain his breath at his usual higher speeds. He’d slow down when running with friends and would start to feel breathless with other types of exercise, like cycling. The discomfort varied in intensity, and sometimes he felt it in his chest, back or throat.
Fenn always led an active, healthy lifestyle. As far as he knew, he had no family history of heart disease. “Honestly, I’m not a person that’s had health problems,” he says. “What I like doctors for is to validate what great shape I’m in.”
To be on the safe side, he went to a cardiologist and passed a treadmill stress test and other heart exams. Lung and gastric work-ups also came back normal. But after several months, a second opinion and repeat cardiac work-up, Fenn learned he had major blockages (70, 80 and 90 percent) in his primary coronary arteries. Fenn says he was “dumbstruck” to learn the extent of his heart disease and that he needed coronary artery bypass grafting, otherwise known as CABG.
Dangerous Blockage
When coronary arteries are blocked and narrow, they can’t provide enough oxygen-rich blood to the heart to meet its demand. That can lead to chest pain, or angina, and eventually a heart attack. Some people who have heart attacks never experience angina pain.
The left and right coronary arteries lead to the heart, with the left artery breaking off into two branches, the left anterior descending and the circumflex. The piece they have in common — the stem to the branches — is called the left main. (A lesion to the left main is known as “the widow maker.”)
Thoralf Sundt, chief of cardiac surgery at Massachusetts General Hospital, says people with left main disease, as well as disease of the three major coronary arteries, or problems with the function of the left ventricle — the main pumping chamber of the heart — are possible candidates for CABG.
CABG (pronounced “cabbage”) and balloon angioplasty are the main procedures used for revascularization — restoring blood flow to the body. Balloon angioplasty is less invasive — the chest isn’t opened and there’s no need for the heart-lung machine. Which option is better depends on a variety of factors, such as how much blockage there is and whether patients have other medical conditions, like diabetes.
Long-term durability is another consideration, Sundt says. He points to comparison studies that found CABG patients need repeat revascularization less frequently. So while it’s easier to recover from angioplasty, he says, you’re likelier to have long-term relief with bypass surgery.
Second Opinions Matter
Aaron Baggish, a cardiologist at Massachusetts General and one of the medical directors for the Boston Marathon, is an expert at the intersection of heart health and athletics. As Fenn’s exercise-related symptoms continued, a friend suggested he see Baggish for a second opinion. Fenn did, and underwent a second stress test, now on an indoor bike. It lasted much longer than his first test, he says, and this time his heart rate was brought up to its maximum. The prolonged test revealed indications of potential blockage.
Next step was cardiac catheterization, to confirm whether there was blockage and if so, how much. In cardiac catheterization, a thin tube is inserted into the heart via an artery in the groin or arm, and a type of specialized X-ray and contrast dye is used to visualize the heart muscle and vessels.
If significant blockage is found during a diagnostic catheterization procedure, it’s decision time. Does the interventional cardiologist perform a balloon angioplasty then and there? Or is there a chance to consult with a cardiac surgeon to discuss the CABG option as well?
Sundt, the cardiac surgeon who eventually performed Fenn’s CABG, says ideally these decisions are made with a heart team approach, including the clinical cardiologist, interventional cardiologist and cardiac surgeon — and the patient. When patients are going through the informed consent process for catheterization, Sundt says, it’s reasonable to ask the cardiologist if others will consult on the decision process.
Major Surgery
CABG involves an incision down the middle of the chest or sternum, a sternotomy, which allows the ribs to be spread to provide access to the heart. In the standard operation, patients are connected to a heart-lung machine so the heart can be stopped while the cardiac surgeon performs the bypass procedure.
An alternative, less-invasive “off pump” technique has been developed. However, Sundt says, that technique is more difficult to perform. A 2012 Cochrane review found better long-term survival with traditional CABG using the heart-lung machine.
Bypass is grafting a person’s own blood vessels to use as new conduits for blood to pass around the areas of blockage and circulate to the heart. Either saphenous veins in patients’ legs, the internal thoracic arteries in their chest wall or parts of both are used to create the bypass graft. Sundt says for patients under 70, there’s an advantage to using multiple arterial grafts, rather than grafts from the leg vein, because they tend to last longer.
In most centers, the operative risk of death with CABG is 1 percent or 2 percent, Sundt says. While that’s considered “quite low,” he says, it’s still not zero and “heart surgery is still a very serious business.” Possible complications including bleeding or infection, stroke, kidney failure and heart attack during the procedure.
The operation takes about four or five hours, and most patient spend at least one night in the ICU, and about five days in the hospital. Patients receive IV narcotics right after surgery, but most are taking Tylenol and possibly Percocet at night by the time they go home.
Milestones
On a Tuesday in May, Sundt performed Fenn’s surgery. Fenn spent a single night in the ICU, “and that’s a tough night,” he recalls. “Because when you come out of heart surgery, you’re kind of a mess.” But by the next day he was transferred to a step-down unit. After showing that he could stand, walk around the unit and negotiate stairs, he was discharged that Saturday.
“Really, the only big drag of the surgery, once you got past days two, three and four, is the sternotomy,” Fenn says. It’s not so much the incisional pain, he says, but the soft-tissue damage. Driving is restricted for several weeks, to avoid the possibility of an air bag to the chest, and there are lifting restrictions as well.
Fenn felt fully recovered by 10 weeks or so — except when he went running. He couldn’t make it past a few blocks and was getting frustrated. But suddenly at 12 weeks, he could run again. Now, he’s building his pace and distance back up to what it used to be.
Sundt says once the surgery is done, patients “should have an attitude that they’re fixed, and they are themselves again, and they can do everything.” CABG is “an incredibly effective operation,” he says. “It really impacts lives; it really saves lives. And people can go for many, many years.”
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CABG: Restoring Blood Flow to Your Heart originally appeared on usnews.com
