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A USER’S GUIDE OF YOUR HEART: TREATING THE HEART
An ounce of prevention is worth a pound of cure. Of course that’s easy to say after the damage has been done, and in some cases dramatic measures must be taken to help a heart. Needless to say, doctors should and usually do take the most conservative approaches first. Diet, an exercise program, and medications may do the job well. But if all else fails, one can turn to today’s medical innovations, approaches that were not available, unfortunately, when my father and many, many others had their heart attacks and died.
Pacemakers. Pacemakers provide a marvellous example of how a relatively simple procedure can save a life. A mechanical pacemaker can be implanted to replace or assist your natural pacemaker, the sinoatrial node, if it isn’t “sparking” your heart to beat properly.
Several types of pacemakers are available. Fixed-rate pacemakers maintain a steady rate of impulses regardless of what the heart itself is doing. Demand pacemakers kick in only when the unit detects a slow heart rate or missed beats. Still others sense the start of the cardiac cycle and pass that signal on to the part of the heart with blocked circuits.
The procedure for implanting a pacemaker is done under local anaesthesia. A physician makes a small incision and threads an electrode wire through a large neck vein directly into the portion of the heart that requires stimulation. A dual-chamber pacemaker sends one electrode into the atrium and another into the ventricle.
The pacemaker itself is then implanted, usually under the skin of the collarbone. Pacemakers operate without a hitch, typically, for many years. Pacemakers left outside the body are only temporary.
Angioplasty What if you could simply push your arterial blockage out of the way so blood could flow more freely? That, indeed, is the principle behind the technique, the full name of which is percutaneous transluminal coronary angioplasty, or PTCA. The method is to thread a catheter through the arterial system to the heart, and then into the coronary arteries which are blocked. When the catheter reaches the blockage, a tiny balloon expands to squeeze the plaque into the lining of the artery.
Approximately 250,000 angioplasties are performed in America each year as an alternative to the more serious open-heart bypass surgery. About 30 per cent of patients experience restenosis, or re-clogging of the artery shortly after the procedure. They require either another angioplasty or surgery.
If you might have an angioplasty in the future, you should be aware that research has shown that taking fish oil capsules prior to the procedure dramatically reduces the occurrence of restenosis. In research done at the Washington Hospital Center in Seattle, patients received nine fish oil capsules daily for a total of 4.5 grams of omega-3 fatty acids for six months before angioplasty. This was done in conjunction with a low-fat diet. Six months after the angioplasty, 35.4 per cent of those who had not taken the capsules showed signs of re-narrowing of the arteries; the recurrence rate among those who had received fish oil was 19 per cent.
Certainly some patients may not have six months before angioplasty. But if you do have such a waiting period, you would be wise to discuss this option with your cardiologist. Also, these findings do not justify taking fish oil for other patients.
Investigators are looking for other ways to eliminate the blockage without surgery. Doctors have begun using lasers to burn away plaques. Laser angioplasty doesn’t just compress a blockage, it actually vaporises it. This procedure is no longer viewed as experimental, but restenosis of 30 to 40 per cent remains a problem.
Coronary Atherectomy. This is another method, by which a tiny rotating blade threaded inside a catheter is used to clean the arteries. One method involves a blade spinning at 2500 revolutions per minute, shaving off plaque. Balloon angioplasty might be performed afterward to push any leftover debris into the vessel wall. This technique has been used at only a few American centres, but it has great promise.
Coronary Artery Bypass Graft (CABG) Surgery. If medications and other treatments either fail to correct arterial blockage or appear to be inadequate for the individual case, surgery remains the principle method for repair. While still considered a major operation, CABG has become quite common and thousands of us wear the telltale scar on our chests. More than half of the men and women who undergo a CABG are under the age of 65.
The name tells it all. This is a procedure by which blood flow is shunted around portions of blocked arteries in the same way that traffic might be detoured around a construction zone. The surgeon will choose either the saphenous veins from the legs or the internal mammary arteries (also termed the internal thoracic arteries) in the chest to make the bypasses needed; sometimes a combination of the two will be needed.
The procedure, with two surgeons in attendance, is performed under general anaesthetic and can take five hours or longer, depending on the number of grafts and any special circumstances. As the operation begins, one surgeon opens the chest, spreads the rib cage after cutting through the breast bone or sternum, seals bleeding vessels, and cuts through the pericardium, while the second surgeon harvests veins for the grafts.
Next, the patient is put on a heart-lung machine, which completely takes over for his own heart and lungs. This permits the surgeons to work on a still heart as opposed to a moving one. The various arteries and veins leading in and out of the heart are clamped off while the heart-lung machine operates. With an experienced team, amazingly little blood is lost, and transfusions can be avoided.
The surgeon then sews the grafts to the aorta and over the affected arteries to a point where the artery is not blocked or narrowed. Once all the grafts are in place, the patient is disconnected from the heart-lung machine and his organs take over breathing and circulation once again.
Finally the surgeons close the chest, wiring closed the rib cage, and the patient is sent to recover. After a day or so in intensive care, the patient returns to a regular hospital room to continue recuperation. Hospital stays vary, but average seven to ten days, and it may be up to six weeks before return to the full spectrum of normal activities and work. Of course, some patients do particularly well, and are up and about in no time at all.
Enormous progress has been made since CABG was first performed at the Cleveland Clinic in 1967 on a regular basis. My first surgery in 1978 was highly traumatic. I lost 14 units of blood and was kept unconscious in recovery with tubes down my throat for over 24 hours.
It was a full year before I felt fully recovered, at least physically. For 12 months I was easily tired, cried frequently, and was extremely irritable. And, of course, I remained in a state of virtual limbo until the time I had the second surgery.
My second surgery was, in comparison, a resort holiday. Even though it was a “re-do” I lost absolutely no blood; in these days of fear of infection that, indeed, was a blessing. Recovery was short and my lungs did not fill with mucus from disuse as was the case the first time around. My stay in the hospital was brief, and nurses had me walking the halls early on. Two weeks after I walked into the hospital, I was back at the typewriter. Within a month I was back to normal, doing my rehabilitation program and well on my way to total recovery.
While there has been some controversy as to whether bypass surgery is performed too often, without sufficient justification, long-term studies at Duke University sponsored by the National Center for Health Services Research and Health Care Technology Assessment have shown that CABG does indeed give one a better chance at a longer life than if heart disease is treated medically. It’s also important to recognise one major difference between the time CABG was begun and the situation today.
In the old days, CABG was viewed as a cure. One had the surgery and went back to the same lifestyle that had helped precipitate the disease in the first place. Moreover, the number of arteries that closed down early after the surgery was much greater than it is today, thanks to drugs and techniques used to keep bypass vessels patent, that is, open and flowing.
When I had the opportunity to observe Dr Jack Sternlieb perform two of the procedures at the Heart Institute of the Desert in Rancho Mirage, California, I was amazed and impressed as to how smoothly the surgery can be done. There was none of the Hollywood-style chaos and yelling and sweating. Instead I watched a practised team expertly orchestrate their movements. Hours later I spoke to the patients as they lay in their beds. That was in 1990, and progress continues.
But while CABG has become routine, one cannot assume that every cardiac surgeon and every hospital will have equal success. If you face the prospect of having bypass surgery, you owe it to yourself to do some careful research in advance. Every hospital must make its records available to you. You have a right to know how many bypass surgeries are done weekly and what the success rates are at the hospital you might enter and for the surgeon who might do the procedure. Shockingly, mortality rates for CABG vary from as low as one per cent or so up to an inexcusably high 15 per cent. You deserve the best! Don’t settle for less.
The material I’ve shared with you on testing and treatment has been necessarily brief. Doctors and hospitals have detailed information on every procedure. Ask for it, read it, and become a fully participating member of your health team.
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