The 100-year anniversary of World War I this year is uncovering new truths. One surprise concerns the origins of heart surgery. To put the breakthrough in context, one should know that in 1896, the standard textbook “Surgery of the Chest” declared: “Surgery of the heart has probably reached the limits set by nature; no new methods and no new discovery can overcome the natural difficulties that attend a wound of the heart.” The leading surgeon in the world at that time, Theodore Billroth from Germany, had gone so far as to declare, “The surgeon who operates on the heart will lose the respect of his colleagues.” Read more
Recent media reports have caused some alarm and confusion about newly published guidelines for statin drugs. Statin drugs reduce cholesterol levels and also decrease cardiac and vascular disease, independent of their cholesterol-lowering effect. Statins provide multiple benefits, but the mechanisms of their actions are not yet fully understood. Like any medication, there is a risk of side effects, which can occur in up to 18 percent of patients and most often consist of muscle pain or temporary derangement of liver function. Rare serious side effects have been described. Read more
A recent article in the financial press (Bloomberg) drew wide attention to inappropriate and excessive use of stents in patients with coronary artery disease (disease in the vessels that supply blood to the heart). Stents are tiny mesh tubes placed in a diseased coronary artery to “prop” it open after a narrowed segment of it has been expanded by a balloon. Read more
Pulmonary embolism is a common and dangerous condition that occurs when blood clots (deep venous thrombosis, or, DVT) break loose and travel from where the clots formed—mostly the leg veins (or, uncommonly, veins elsewhere)—to the pulmonary arteries, which conduct blood from the heart to the lungs. Sometimes these clots are small and may not cause clinical symptoms, because the surface area of the lungs, when opened out, would cover the surface of two tennis courts! However, occasionally, a pulmonary embolism can be massive and rapidly fatal. Read more
When first seeing a specialist for a new medical problem, many patients simply show up at the appointed time and place, trying to suppress their fears and anxiety, and too passively go through the process of history, physical examination and discussion.
When you have a new doctor, taking a more active role will lead to a better and more productive appointment. Read more
When deciding on which car or college — or, increasingly, health care provider — to choose, many of us compare reviews and ratings in such sources as Consumer Reports and U.S. News & World Report. More than two decades ago, the New York State Department of Health, itself, began to report information on cardiac surgery because the Commissioner of Health noticed wide variations in mortality rate and complications reported by different hospitals in the state. Read more
The FREEDOM clinical trial, a study of 1,900 diabetic patients, just reported in the prestigious New England Journal of Medicine that diabetics with multi-vessel coronary disease who were treated with coronary artery bypass surgery (CABG) fared much better than those treated with angioplasty with drug-eluting stents (percutaneous coronary intervention, or PCI.)
CABG improves blood flow to the heart by grafting (connecting) a healthy artery or vein from another part of the body to the blocked coronary artery, thereby rerouting blood around the clogged portion. PCI is a medical procedure that uses a small balloon to widen the blocked artery so that a tiny, medicine-coated mesh tube, or stent, can be permanently placed inside it and keep it propped open.
A Game Changer
With diabetes on the rise, treatment based on strong scientific evidence is important not only for the individual, but also for health care systems. In addition to the favorable medical results, the study found that CABG is cost effective for treating multi-vessel disease, mainly because CABG patients needed few additional procedures after their operation.
The lead author of the trial said the findings would “absolutely change clinical practice,” and the writer of the accompanying editorial described the study as “compelling” and renewed calls for heart teams to inform diabetic patients properly of the survival benefits of CABG.
Cardiac surgeons are not surprised by the FREEDOM trial findings, because they match previous studies comparing CABG and PCI for diabetics. Through CABG, surgeons provide a durable operation with substantially improved long-term results and a reduced need for further procedures.
Not Your Grandmother’s Operation
Compared to traditional surgery, the standard CABG operation of today uses a minimally invasive approach to harvest veins through a small incision in the thigh, offering better protection of the heart, better strategies for preventing stroke and improved patient comfort and healing.
The type of blood vessel used for a bypass graft is key, because arterial grafts from your chest or arm are far more likely to stay open over 15 or more years than vein grafts from your legs. Patients with open grafts survive longer and suffer fewer heart attacks, as reported in the scientific literature by Beth Israel Medical Center and others.
On the Cutting Edge
While most centers use the left internal thoracic artery (LITA) as the only arterial graft, Beth Israel is a leading center for use of the radial artery, located in the forearm, for CABG surgery. Since 2000, our expert team has harvested the artery using a surgical telescope via a small incision (2.5 cm) at the wrist, and we remain one of very few medical centers to offer this minimally invasive technique. We use the LITA and one or both radial arteries to create multiple arterial bypasses and restore healthy blood flow to the heart.
Published studies of a large series of patients from Beth Israel (and reports from other centers) have established and confirmed the dramatic benefit of the radial artery graft specifically for diabetic patients.
Bypass Surgery the Clear Winner
Patients with diabetes should understand that the scientific evidence clearly supports bypass surgery as the correct treatment for multi-vessel coronary disease, and consultation with the Heart Team at Beth Israel will direct patients to surgery when appropriate.
To find a cardiac care team that is right for you, please call the Physician Referral Service at 1 (866) 804-1007 Monday through Friday, 9 am to 5 pm.
Recently, my wife paged me during a clinical meeting. “Call Mom urgently!” After negotiating the practical challenges of placing an international call from New York to South Africa while trying to guess what the crisis was, I was told my dad was in the operating room. His surgeon had just emerged to say that my father had cancer, which had spread to the liver (bad) and the lining of the abdominal cavity (worse). There was “nothing to be done.”
Three months earlier, I walked the golf course with my dad, who was still working full-time in his mid 70s and with no apparent health issues! Now the nightmare of every immigrant who left loved ones behind was my reality.
This scenario is not unusual now as we live in a mobile society. Our parents, children or relatives who may be far away from you might face serious illness and need help. Here are some tips on how to manage the crisis:
* Manage yourself. Stay calm and prioritize. Colleagues and family will respond to your request for urgent practical help so that you can work simultaneously or cover your commitments and hold the fort for you at home. They can also help you locate resources to draw on.
* Manage the family. Smaller families, spread out in different places coupled with the stresses of modern life all reduce the chance that there is someone in the family who is completely free to assume the role of caregiver. One family member should, however, assume a leadership role and can act as a spokesperson transmitting information to the rest of the family, as well as to the doctors.
* Gather information. Start to compile lists about the diagnosis and the planned course of treatment, as well as the prognosis. Are there alternatives to the proposed treatment? Clinical trials for this disease? The Internet is a fabulous resource for information, but even as a physician who speaks the language of “Medicine,” information on the Internet is unfiltered and can be very confusing. Start with reputable sites like the American Heart Association (www.heart.org), American Cancer Society (www.cancer.org) or the National Institutes of Health (www.health.nih.gov).
* Weigh the Information. Well-meant platitudes or the experience of someone’s cousin or nail lady is not necessarily relevant to your relative’s situation. When I had a rare and life-threatening cancer myself, I was told by an acquaintance that if one had to have a cancer, mine was the sort one would choose. (So wrong!) Enlist help from someone who understands the technical language to interpret the results of your searches. The family caregiver alliance is a very useful resource (www.caregiver.org).
* Talk to the doctor. Once you have permission from the patient, an introductory phone call can be useful. Email is especially useful for back and forth communication and used by most physicians especially if distance and time zones are an issue. When you travel, try to see the patient’s doctor face to face. Have a prepared list of written questions and get someone to accompany you to help record answers and impressions and supplement your questions. Try to set up a timeline and goals for treatment so you can plan future trips.
* Talk to the other care providers. Nurses in both hospital and outpatient settings, physician assistants and nurse practitioners are all invaluable sources of information about the treatment course and practical issues. Build a relationship with them, as they will undertake much of the patient care. Again, have the patient make his or her wishes clear that you can have access to medical information.
* Consider practical matters. Set up a plan for care including transportation, nutrition, and exercise (physical and mental). Ask for and accept specific help from friends, family and others where you live and where your loved one is. People will want to help, but you need to be specific with each offer (walk my dog/fetch me from the airport/find me the name of a specific specialist for a second opinion). When far away, religious community leaders can be a useful resource.
* Plan for emergencies. In the worst case scenario, a call to 911 can result in a patient being deposited in the emergency room of the nearest hospital where no one knows the patient history and time might be wasted and painful tests repeated unnecessarily! Avoid this and create an emergency packet that can go with the patient. Include a list of essential phone numbers and names, a list of medicines and allergies, a list of doctors and their phone numbers, and a timeline of the medical history.
* Pace yourself. Remember to conserve your own health. I tell my patients’ relatives that major illness is not a sprint event but a marathon and you need to pace yourself accordingly. Try for a healthy diet, maintain or increase your exercise level (to counteract the stress and all that sitting in waiting rooms), and try to get enough sleep and rest. Get help from your own doctor if needed.
Darryl M. Hoffman, MD, is a Cardiac Surgeon at Beth Israel Medical Center.
Over the past 50 years, the treatment of heart conditions has benefitted from many dramatic developments. Sometimes, however, patients are confused by the different options and medical opinions. Should you go for a stent or a bypass or just medication? Should you see a cardiac surgeon or an interventional cardiologist? There are no pat answers. This is why experts now believe that a team approach is essential to help you select the best course of action.
It hasn’t always been this way…
Bypass vs. Stents
Inherited abnormalities, diseased heart valves and blockages of the coronary arteries have been studied for over half a century and creative ways were found to diagnose and fix many problems. Along the way, there were useful improvements in protecting heart muscle, making anesthesia safer, helping the failing heart and providing high-tech care in specialized intensive care units.
An epidemic of coronary disease made coronary bypass surgery the most frequently performed and best-studied operation in human history with impressive success rates. The use of catheters from the groin, to inflate tiny balloons to dilate coronary blockages and insert metal mesh stents to prop open artery walls was also a major development in treating the heart.
Cardiac Surgeons vs. Interventional Cardiologists
For a time, heart surgeons who advocated the proven benefits of coronary bypass surgery and interventional cardiologists who offered the evolving stent techniques seemed to be in adversarial positions. Hospital meetings and national conferences were enlivened by heated debates. Complicating matters, some techniques showed promise, but later turned out to be ineffective or even harmful. Since that time, careful and objective scientific studies have defined more accurately the exact circumstances that are best treated by surgery or stents or even medications.
What Approach is Right for You?
At Beth Israel Medical Center, every heart patient consults with a team of both surgeons and cardiologists. Guided by the standards of professional societies like the American Heart Association and the American College of Cardiology, the heart team recommends a carefully considered and personalized course of action based on the patient’s specific disease and general condition, as well as the latest scientific evidence.Darryl M. Hoffman, MD, is an attending physician at Beth Israel Medical Center.