- The decision to undergo heart surgery is a complex one
- Options range from open heart surgery to minimally invasive techniques
- In the end, the decision to operate depends on a patient’s unique
Coping with heart disease can be difficult, but the prospect of surgery
to repair an artery or valve can be even more daunting. There are many
procedures out there — from open heart surgery to minimally invasive
techniques such as coronary artery stenting and
transcatheter aortic valve replacement (TAVR) — not to mention the multiple factors involved in deciding when
surgery is the best option.
That’s why it’s important to have a physician knowledgeable
about how to treat heart health — and when it’s time to move
forward with surgery.
Michael Ring, MD, co-director of the TAVR program at
Providence Sacred Heart Medical Center and the Medical Director of Quality at the
Providence Spokane Heart Institute, talks about that decision from the physician and patient perspectives.
Generally, patients are dealing with two types of issues: coronary artery
disease caused by cholesterol plaque buildup, or problems with one or
more of the heart’s four valves that cause improper blood flow.
For the first group of patients, medication is usually the first approach
before surgery is even considered, Dr. Ring says. “The majority
of these patients are given medicines to help prevent progression of the
disease. Even patients having symptoms can manage them medically for the
most part. The ones who would end up getting surgery are typically patients
who have a high-risk situation such as a recent heart attack or a severe
blockage that puts a large amount of heart muscle at risk.”
For treating valvular heart problems, physicians rely on guidelines developed
by professional societies such as the American College of Cardiology,
the American Heart Association and the Society for Thoracic Surgery, says Dr. Ring.
“These guidelines combine what we see from an anatomical viewpoint
— the severity of the problem, how it affects heart function —
and symptoms attributable to valvular heart disease that can’t be
managed.” Those symptoms include:
- Shortness of breath, especially with exertion or after laying flat for
a period of time, caused by fluid backup in the lungs when the heart can’t
properly pump blood forward
- Edema or swelling in legs, especially late in the day, because the body
can’t clear fluid
- Chest pain or tightness with exertion
When diagnosing a valve problem, a primary care doctor usually detects a
heart murmur and sends the patient to a cardiologist, or takes the first step of ordering
an echocardiogram. “That’s an ultrasound of the heart and
is probably the best initial screening test to assess valve function,”
Dr. Ring says.
When it comes to any type of heart surgery, physicians consider several
factors to determine the risk of the procedure — age, weight, lung
and liver function, and other things that affect the surgery, such as
a patient’s health history. “There are also certain subjective
things we look at as well,” Dr. Ring says. “For example, there’s
frailty, the overall condition of the patient and how physically fit they
are. Some individuals may have aged well and has good mobility and fitness,
while someone else, because of their genetics or lifestyle, may have significant
arthritis and/or deconditioning and needs to get around with a walker
or cane, and that kind of patient can have difficulty recovering from
open heart surgery.”
Additionally, understanding the cause is a diseased valve is important
to decipher. “Some valve abnormalities, such as secondary mitral
regurgitation-can improve with medicines alone,” said Ankie Amos,
M.D., cardiologist with the Alaska Heart and Vascular Institute in Anchorage.
“Several tests such as heart catheterization, cardiac MRI, and transesophageal
echo can help answer this question.”
Once the cause is determined, a team approach between a cardiologist and
surgeon is imperative as many factors go into the decision of when to
act on a diseased valve, Dr. Amos added.
There are a few things patients should make sure they understand when it
comes to heart surgery, Dr. Ring says:
- What exactly is the problem — what is wrong with the heart and how
that is impacting them
- How confident is the physician in the evaluation and whether further testing
or other medical opinions are needed
- How will surgery affect quality and/or duration of life, or any other co-existing
- What are the risks with the surgery, which are specific to each patient’s condition
With so many variables, patients should also feel comfortable with their
doctor and their treatment plan. “If something doesn’t seem
right, to get another opinion can give patients some additional insight
or it can also give some confidence that their decision is as informed
as possible,” Dr. Ring says. “Realize too that the cardiologist
is one part of a heart team which includes other cardiovascular specialists
as well as belonging to a hospital system. It is essential that the patient
consider the experience and reputation of the entire heart team when contemplating
possible heart surgery”.
A physician should also be able to clearly explain each type of surgical
option to patients.
“There are conventional surgeries that for the most part represent
opening the chest with what we call a sternotomy and placing the patient’s
heart on a heart-lung machine that temporarily takes over pumping the
blood and allows you to stop the heart so you can operate on it safely,”
Dr. Ring says. “So that’s the most common thing when we talk
about open heart surgery, and it’s the most invasive form of surgery.”
On the other end of the spectrum, there are transcatheter, or minimally
invasive, valve repair techniques. “An example of that would be
TAVR,” Dr. Ring says. “You would go through the groin or other
areas to avoid opening the chest, and if we did have to go through the
chest, it would be a much smaller incision and usually not involve the
Dr. Ring adds that there has been growing interest in the procedure and
its ability to restore one’s quality of life, from
patients and physicians. “A lot of patients find it difficult to recover
from a sternotomy and they inherently don’t like having that procedure,” he says.
For patients with coronary artery disease, a similar minimally invasive
technique would be coronary stent placement. “With a stent, the
arteries are pretty small, about 3 millimeters in size, which allows access
to the heart through the groin or wrist with a small catheter. It’s
a small puncture site and you don’t have to stop the heart —
it’s a pretty straightforward process that’s evolved over
the last couple of decades and can be done at fairly low risk.”
In between those two extremes of catheter-based procedures and full-blown
open heart surgery are other evolving techniques. “As an example, with
robotic surgery, which is performed at a high volume at our institution, usually for mitral
valve surgery, you can go in with small robotically controlled instruments
and get to the valve using several small incision sites in the chest.
It’s surgery, but it avoids a sternotomy and the recovery from it
is typically much shorter and less severe than conventional open heart
For more information on cardiac health and surgical options, talk with
a physician at one of these locations or
find a physician near you.
This information is not intended as a substitute for professional medical
care. Always follow your healthcare professional's instructions.