Who Should Get a Bypass?

Wednesday, 11 Jun 2014 04:28 PM

By Chauncey Crandall, M.D.

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The bottom line is that bypass surgery should be considered a treatment of last resort. There are cases in which bypass surgery remains the best course. But those cases occur far less frequently today because of medical advances.
 
I recommend beginning with the least-traumatic, least-invasive measures possible. This is not merely a matter of kindness; less trauma is always better for a patient’s long-term health.
 
If at all possible, you should involve loved ones and your primary care physician in the decision, because those are the people who know you best and care about you most. If your condition is stable enough to allow it, take the time to get a second opinion. If you are already in the hospital, your insurance company probably will cover the extra cost. If you have been treated strictly on an outpatient basis, insurance might cover the extra cost, but you’ll need to check.

Bypass surgery may be indicated for three groups:
 
1.     Critical heart disease. Blockages of 75 percent or greater in at least three vessels, along with associated depressed left ventricular function. This refers to the heart’s “ejection fraction,” or its ability to discharge the blood in its chambers. If this ratio has fallen to less than 35 percent, you are a candidate for bypass surgery. Keep in mind that critical blockage must be present in three vessels. It’s often the case that one vessel is almost totally blocked while the remaining vessels have less serious blockages. This allows for a different course of treatment.
 
2.     Critical left main (left anterior descending) artery disease of more than 75 percent. These patients may be treated with bypass surgery, but don’t necessarily need a bypass. These cases are challenging to diagnose, and treatment often depends on the skill of the physicians involved.
 
3.      Diabetics with three-vessel coronary disease. The percentage of blockage in all three of a diabetic’s vessels does not have to rise to the threshold of non-diabetics (i.e., 75 percent), because diabetics are less able to take advantage of less-invasive measures and lifestyle change.
 
Bypass surgery used to be regarded almost as a panacea, with patients undergoing multiple bypass surgeries over the course of their lives. But 20 years ago doctors had fewer options, and merely offered whatever help they could to patients with critical heart disease.
 
Today, we have other options. And if we do perform a bypass, we want the first surgery to be the last. The good news is that we’ve learned so much more about heart disease that, with the patient’s cooperation, that outcome is possible.

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