Learn About Your Heart...
Made Simple


By Nicolas Shammas, MD


A new, comprehensive sourcebook for
heart and vascular disease patients

Cardiovascular Health Topics



1.
Statistics about Heart and Blood Vessel Diseases in the United States
2.
Structure and Function of the Heart and Blood Vessels
3.
Diseases of the Blood Vessels of the Heart
4.
Surgical Therapies for the Cardiovascular Patient
5.
Peripheral Vascular Disease
6.
Diseases of the Blood Vessels of the Head and Neck
7.
Strokes: How to Survive Them and How to Prevent Them
8.
Valvular Heart Disease
9.
Heart Rhythms: How to Recognize Them and Treat Them
10.
Congestive Heart Failure
11. Understanding Cardiomyopathy, or Weak Heart Muscle
12. Children and Heart Disease
13. Diseases of the Pericardium
14. Systemic Illnesses, Infections and Drugs that Affect the Heart
15. Erectile Dysfunction: a Vascular Disease
16. Cardiovascular Disease Prevention
17. Heart Healthy Nutritional Tips
18. Cardiac Rehabilitation
19. Medications for Cardiovascular Disorders
20. Heart Tests You Need to Know
21. Learn What to Do in a Medical Emergency
22. How to Choose Your Doctor and Hospital
23. Medical Research and How You Can Get Involved
24. Taking the Next Step — A Few Community Resources to Help You Live More Healthfully
25. How Much Did You Learn from This Book: Take a Simple Test



SURGICAL THERAPIES FOR THE CARDIOVASCULAR PATIENT

Nicholas V. Augelli, MD

What will this chapter discuss regarding cardiac surgery? Although the area of cardiac surgery has grown quite complex in the last 10 years, the mortality rate for all procedures has decreased even though the degree of sickness in the patient, as well as the age of the patient, has increased.

When someone needs cardiac surgery, the first question we face as cardiothoracic surgeons is, "Why can't they do angioplasty?"

First of all, angioplasty—a process through which a cardiologist passes a balloon through blocked arteries—is not appropriate for all conditions, and many times when your cardiologist calls upon cardiac surgeons to intervene, he or she has already determined that another treatment is necessary.

To explain cardiac surgery in laypersons' terms, this chapter will discuss the conditions that might make it necessary for someone to need heart surgery and will divide the conditions into 2 categories: those that need immediate attention and those that require more time to evaluate and prepare the patient.

What are aortic dissections, and why is surgery necessary?

"My friend just collapsed, and before collapsing, he said he felt like his insides had ripped. He had a very sharp pain in his back and front. Is this a heart attack? What could it be?"

Not all collapses or sharp pains to the chest area are heart attacks, although some of them are.What your friend most likely has is an aortic dissection. This happens when the aorta (the blood vessel that carries blood to the entire body) breaks and separates into 2 linings, 1 of which ruptures, spilling blood. This blood can then compress the heart and cause the blood pressure to become quite low. Many people die before making it to the hospital. Your friend was lucky enough to come to the emergency room and have his condition identified by an ultrasound examination or a special x-ray; the surgeons were then called, and surgery was done emergently to stop the bleeding and repair the ruptured portion of the aorta.

Aortic dissections can occur in either the ascending portion of the aorta (the part that comes immediately out of the heart and is in the chest cavity) or in the descending portion of the aorta (the part that is mostly in the abdomen). The surgery required depends on the start of the rupture as well as the extent and severity of blood spillage that has occurred.

Many times these patients have high blood pressure (hypertension). Once patients recover, they need to take antihypertension medications and be followed for the rest of their lives for good blood pressure control as well as the possible occurrence of an aneurysm of the aorta.

What are aneurysms and what problems do these present?

An aneurysm is an enlargement of a blood vessel. When aneurysms grow large enough, they can spontaneously rupture. Doctors follow aneurysms in various parts of the body. In the aorta, an aneurysm greater than 2 inches is of concern, and your doctor may ask you to see a surgeon to help manage this problem. Aneurysms that rupture are treated as medical emergencies, much the same as aortic dissections, while the aneurysms that slowly grow are treated electively until surgery becomes indicated.

What is the surgical treatment of coronary artery disease? You get a call from your brother—he is in the hospital. Last evening, he had a heavy meal, he went to bed, and he felt indigestion. At 4:00 this morning, nothing made it better, and his wife called 9-1-1. You now find out from your sister-in-law that he has had a major heart attack and will need surgery because angioplasty is not possible given the amount of disease present. You want to know how this could be happening. Was he having any trouble before? How long does he need to wait before he can have surgery safely?

The next morning you talk to your brother, who tells you that he was having problems for about 3 of 4 months, he was using more antacids, and he would come home after work exhausted and usually fall asleep right after dinner. He didn't think much of it, since he was turning 65 years old and soon would retire from work. He further tells you that his surgery will be in 1 week because he had "Plavix." It makes him more likely to bleed, and the doctors need him off this medication for a week to make it safe for surgery. You are shocked."Can this happen to me?" you ask in disbelief. "After all, our mother and father died of heart attacks in their 60s, and our sister had a heart attack last year."

You decide it is time to go in and see your doctor. He tells you that you are overweight, you have high blood pressure, and your cholesterol is elevated. You are also running slightly higher than normal blood sugars, and a blood test did show you may be at higher risk for diabetes.Your doctor wants you to start a diet regimen and take blood pressure medicine, and he starts you on a cholesterol-lowering medicine.You are pleased yet still worried about your brother, and you ask your doctor to explain coronary bypass surgery.

Coronary bypass surgery is a procedure where arteries (radial, or from the arm, internal thoracic, or mammary, or from under the collar bone) and veins, primarily from the legs, are taken to create little hoses to bring blood from the aorta (the major blood flow unit of the body) to the heart blood vessels. The heart has 2 main coronary arteries, a left and a right. These 2 vessels have many branches and visually look like the branching on a tree with the heart muscle being the leaves at the end of all those branches. Bypasses allow blood to go past points of blockages so that the heart can nourish itself again and heal. However, receiving bypasses by itself will not take care of the problem of blockage buildup. Coronary bypass surgery does not cure atherosclerosis (plaque buildup in the arteries). To control this disease, which has no cure, one must control its associated risk factors, some of which are smoking, high blood pressure, diabetes, high cholesterol levels, age greater than 45, male gender, and strong family history of heart disease.

Your brother's odds with surgery are also better today than a decade ago. You meet with your brother and share with him what you have just learned. He goes on to have surgery, and afterward, you decide to join him for his cardiac rehab sessions. You encourage each other to remain with the program, and gradually, risk factors for both of you fall more into the norms. Your doctor is pleased.

How do we treat valvular disease surgically?

You have just come back from vacation, and you tell your husband that you don't feel well. You feel short of breath and have had the chills. You take your temperature, and the thermometer reads 102°F. You decide to take a few aspirins and go to bed. You will call your doctor in the morning. That night, you can't get comfortable. You come up for air literally several times during the night, finally falling asleep in the recliner. You wake up soaked.Your husband calls the doctor's office, and they will see you at 10:00 am.

Your doctor completes your exam. He has heard a noise in your chest, a murmur. "Explain!" you say. This is what you hear: a murmur is a noise that blood makes when it flows through a damaged valve of the heart. Not all murmurs are bad. The severity of noise is graded on a scale of 0-6. You find out that your murmur is grade 3. Your doctor wants to know more about the history of your health. He has in his history that as a little girl you had scarlet fever, and it left you with a murmur. He also asks you what happened before or during your vacation to Mexico. You mention that you fell and cracked your tooth. By the next day, it was swollen, and you had a low-grade fever. The local dentist was very nice and fixed it for you.You need to see your dentist now, so it can be permanently fixed. "Antibiotics?" he asks. You don't think you received any. He spoke very little English, and there wasn't time, because the pain was so severe. He meant well. Your doctor orders an echocardiogram. This instrument uses sound waves to image the heart, much like sonar used by the military.

You proceed with the test. Afterward, you meet in your doctor's office and you find out you have bacterial endocarditis. "Plain English," you hear yourself say. You hear that you have an infection in 1 of your heart valves. You learn that there are 4 valves in the heart. The valves control the flow of blood in the heart. The heart is really 2 pumps yoked together. The right pump sends blood to the lungs, and the left pump sends blood to the body. The valves that control the inflow of the blood to the heart are the tricuspid and the mitral valves. The valves that control the outflow from the heart are the pulmonic and aortic valves. Valves are very delicate structures and are prone to infection and deterioration from use. You also hear that the scarlet fever you had as a child most likely injured 1 of your valves, and the recent infection further damaged this same valve.


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