For The Inoperable Coronary Patient
There are two important questions that need to be asked every time a heart patient is diagnosed as inoperable:
- What makes a coronary patient inoperable?
- How can we improve on our surgical solutions to save the life of a high risk or inoperable coronary case?
Well, let me give you first a quick, down-to-earth introduction to the technical aspects involved in a coronary bypass. Once you know what the basic technical challenges are, you will appreciate the solutions we have developed in high risk heart surgery cases. These new technologies have made the difference for so many heart patients that were otherwise hopeless and and told that they are inoperable.
A coronary artery bypass operation is essentially a plumbing intervention on blocked coronary arteries. A pipeline (a vein or an arterial graft) is directly connected between the water main supply (the aorta, the main pipeline in the human body) and a spot on the coronary artery downstream from where the blockage is. If any of the steps in this process cannot be carried out within certain standard choices your local doctor might not be able to offer you an operation and might mention the word “inoperable”.
Answers For Inoperable Coronary Patients
Let’s start the list of specific answers to question #1 and question #2. Consider it the troubleshooting chapter of your coronary owner’s manual.
A. The Aorta is heavily calcified and cannot be used to connect the heart-lung machine. A cross clamp to stop the heart and hook up the vein grafts as it is routinely done by most surgeons in coronary bypass surgery. The calcification makes the aorta “crunchy” and unusable. If you try to stick a cannula in it or a clamp across it, it will crack and release small crumbs of calcium into the general circulation, causing serious problems. These crumbs can float to any blood vessel and sort of plug it up, effectively blocking the blood flow to any organ in the body they travel to. If they go to the brain they’ll cause a stroke, if they go to the kidneys they can cause kidney failure and the list of problems goes on for any organ in the body.
Dr. Ciuffo’s Solution: The troubleshooting consists in using what we usually describe as a “no touch” technique. We have designed a radically different surgical approach that completely avoids any manipulation of the aorta but still guarantees an excellent coronary bypass operation. Instead of using the aorta, our “water main supply” will originate from the left and right internal mammary arteries. These vessels run along the chest wall and are already hooked up to the general circulation through the subclavian arteries in our shoulders. This choice gets around the need to use the aorta as the hook up for our pipelines. A beating heart surgery techniques can be used to perform the bypass operation without using the heart-lung machine or any clamp across the aorta. Many surgeons are not properly trained or sufficiently experienced to perform these techniques. If you are told that you are inoperable, it might be time to search for a second opinion in a reputable high risk heart surgery center and inquire if you are a suitable candidate for these options.
B. There are not enough conduits or veins (pipelines) to work with. This situation refers to patients that have run out of usable veins or arteries for a variety of reasons. Here are a few examples. A 50 year old lady might have had her varicose veins stripped out of both legs. A diabetic or a vascular patient had their veins used for a previous coronary bypass operation or a vascular bypass in the leg. A patient might have undergone a leg amputation. A dialysis patient had multiple dialysis access operations on his/her arms and legs.
Dr. Ciuffo’s Solution: What you need to know is that there are many grafting options to help in this situation. We can presently harvest conduits from the arms (radial arteries, basilic veins), from the back of the legs (lesser saphenous veins), from the abdominal wall (epigastric arteries), from the peritoneal cavity (gastroepiploic arteries), from the chest wall (Internal Mammary Arteries). In extreme cases where truly no conduits are available anywhere in the body, human cryopreserved saphenous veins from tissue banks can be thawed out and used. Every coronary case is different and should be carefully evaluated by a medical professional to see if a technical option is available to help an individual patient.
C. The coronary vessels are too severely and diffusely diseased to find a spot to connect the bypass graft. That is a situation most surgeons describe as “bad coronary targets”. Here is the catch: not every surgeon or cardiologist has the same level of technical and clinical experience. What is too diseased and therefore inoperable for a surgeon could be a pretty straightforward target for someone with a specific experience in difficult coronary cases.
Dr. Ciuffo’s Solution: If a coronary vessel has multiple blockages, it is possible to perform double grafting on individual vessels. If the entire length of the coronary is severely diseased, it can be treated with an endoarterectomy, a procedure designed to remove the atherosclerotic plaque (the grime that is clogging up the pipe) to reestablish a good target for bypass grafting.
D. The patient, otherwise clear-minded and independent, is too old and/or frail to withstand an open heart operation. Well here is a good question to ask if you are told that this is the reason why you are inoperable: “Dear doctor, am I not too old and frail to survive my severe heart condition and avoid a miserable end of my life?” To put it in the words of a feisty 86 year old patient of mine: “I might be old but I am not ready to die yet!!” A decision about surgery should not be simply based on age and frailty.
An intelligent conversation has to touch upon each medical or surgical alternative and its related risks and benefits. In other words, if you are told that open heart surgery is very risky you need to know exactly what your chances are. Let’s suppose you are told that you have a 20% risk of serious complications or death with surgery. Your next question should be:”What are my chances without coronary surgery?” You might have a condition severe enough to jeopardize the chance for you to celebrate your next birthday. Then, I guess, 20% risk with surgery would not sound that bad any more. In many cases medical therapy is much more dangerous than said surgery. You need to know what your options are. Needless to say, every case is different and you should always discuss your case with an expert medical professional. Expert minimally invasive and high risk heart surgery centers can offer surgical options that do not involve any bone cutting and can be performed through a tiny 2″ incision and without using a heart lung machine.
E. The patient has any combination of bad lungs, bad kidneys, bad liver and/or a prior open heart operations. Many of the thoughts I expressed in the paragraph D above apply here as well. Know what your chances are with and without surgery. Let’s say you have bad lungs and severe coronary disease. You might be able to breathe better if a good percentage of your breathing problem is caused by a heart condition that could be improved by the surgery. Bad kidneys might not be going to do well if you continue with medical therapy and the heart remains weak and causes congestive heart failure. Bad liver can be a high risk surgical proposition. You need to know how bad it is. There are different stages from mild to severe liver insufficiency and their associated surgical risk can vary a lot from case to case. In all these cases, an experienced heart surgeon could select the use of beating heart surgery techniques to carry out a high risk coronary artery bypass grafting operation. This type of surgery avoids the use of the heart-lung machine and protects kidneys and lungs from potential damage.
F. The heart is too weak. The strength of the heart is commonly measured as Ejection Fraction (EF). A normal EF is 60-65%. The lower the number, the weaker is the heart. The response to this condition can vary significantly among heart specialists. Some surgeons might not be comfortable operating on weak hearts because they feel they might not recover well after surgery. High risk heart surgery specialists might offer a more secure outcome by meticulously managing certain heart conditions before, during and after surgery. The high risk heart patient can be optimized before surgery with adequate preoperative medical intervention, during surgery with advanced minimally invasive and/or beating heart surgery techniques and can then recover postoperatively with expert management of congestive heart failure and low ejection fraction. In coronary patients the heart muscle might be weak because of the coronary blockages and can be revived and strengthened by the bypasses that reestablish a good blood supply to a heart muscle otherwise starved for oxygen.
G. There are other reasons why your doctor might describe your heart condition as inoperable. Please feel free to contact us and discuss your questions and concerns with us.
Second Opinion With Dr. Ciuffo
If you’ve been diagnosed as an inoperable coronary patient for one or more of the reasons listed above, it is important that you talk with our expert heart surgeon, Dr. Giovanni Ciuffo, for a second opinion. Contact us online or call (330) 588-4676 to schedule an appointment with Dr. Ciuffo.