Revascularization Explained

A coronary artery bypass graft, also known as a graft, is recommended for select patients with coronary artery disease and is the most common kind of open-heart surgery in America [source: National Heart Lung and Blood Institute]. During the procedure, a breathing tube is connected to a ventilator that breathes for the patient under sedation. Once the heart is stopped, the heart-lung machine becomes completely responsible for the patient's blood circulation. A cardiothoracic surgeon (a surgeon who specializes in procedures to the chest -- including the heart, lungs, esophagus and their associated blood vessels) begins the operation by taking a healthy blood vessel from another part of the body, usually the leg. After making an incision in the chest, the surgeon will connect the healthy blood vessel to an artery in the heart. This way, blood bypasses the diseased or blocked area and the heart is restored with blood, supplying it with the oxygen and nutrients it was previously lacking.

Risks of complications are highest if the patient is a smoker, older than age 70 or if there is an emergency -- like a heart attack -- that complicates the surgery. For recovering patients, healing typically takes six to 12 weeks, and results are usually very good. According to the National Heart Lung and Blood Institute, after undergoing a coronary artery bypass graft, "85 percent of people have significantly reduced symptoms, less risk of future heart attacks, and a decreased chance of dying within 10 years."

A minimally invasive coronary artery bypass is a less invasive bypass surgery available to those who have a low risk for complications. Patients who undergo this procedure have blockages that can be bypassed through smaller incisions, and it can be performed while the heart is still beating, reducing the likelihood of complications. This surgery also reduces patient recovery time -- recipients of minimally invasive coronary artery bypass surgeries are usually able to leave the hospital in as little as three days. However, if a patient has more than one coronary artery to bypass, a more complicated procedure will be required.

Angina -- defined as chest pain or discomfort -- is a common ailment and symptom of coronary heart disease. This tightening in the chest is caused by poor blood circulation through the heart's major blood vessels and usually occurs after strenuous activity or a bout of stress. This pain comes in two forms: stable angina and unstable angina. Unstable angina is often a sudden, intense pain that is not lessened by rest. It's life-threatening and needs to be treated immediately. Stable angina, however, is usually a manageable condition and is often predictable. For example, a patient with stable angina knows he will likely experience a tightening in the chest after running up and down a flight of stairs, and the pain will subside if he rests for a few moments. Stable angina usually improves with medication, and if a patient makes significant positive changes in his diet and exercise regimen, his chest pain is often reduced considerably. In extreme cases, stable angina can be treated with procedures such as coronary artery bypass surgery or a percutaneous coronary intervention (PCI), formally known as a coronary angioplasty.

The coronary arteries are responsible for carrying oxygen and nutrient-rich blood to the heart. When they become blocked by built-up plaque -- which consists of fat and cholesterol deposits -- a person may experience angina-related chest pain, a heart attack or other heart-related problems. A PCI is a revascularization procedure that allows doctors to open blockages within arteries by using a balloon catheter -- usually with the placement of a stent -- to restore blood flow to the heart.

This may sound complicated, but it's actually pretty simple. A balloon catheter is a tool that can be inserted into a narrow or collapsing artery. Liquid then expands the balloon, which pushes plaque aside and restores the artery to its normal size. If a stent -- a small mesh tube made of fabric or metal -- is needed, a doctor will place it inside an artery to help keep the area open after a PCI has taken place. The stent is usually coated with medication that prevents an artery from constricting or closing again after the surgery has been completed. A PCI is not as traumatic as some of the more complicated revascularization procedures, and patients are typically able to walk within six hours of waking up from anesthesia.

However, not every attempt at a PCI is successful. Read the next page to find out about what kind of revascularization surgery is an option if a bypass or PCI fails.

Transmyocardial revascularization (TMLR) is not a traditional surgery for people suffering from coronary artery disease (CAD). It's usually performed when medicines, PCI or bypass surgery have not been successful treatments. No heart-lung machine is needed for this procedure, and a surgeon operates on the heart while it's beating and full of blood. Unlike a coronary artery bypass graft, surgeons do not cut into the chambers of the heart. Instead, they make an incision in the chest, and a laser cuts tiny channels through the heart muscle and into the left ventricle, which is the heart's main pumping chamber. The laser is usually able to reach areas where bypass grafting cannot, and if the surgery is successful, it will ultimately improve and restore blood flow to this all-important organ.

Complications that can occur during and after TMLR include unstable angina, heart attack and sudden death due to abnormal heart rhythms, also known as arrhythmias. In one examination of TMLR, it's noted that, "The reported mortality rate (7 to 10 percent) following TMLR is a significant cause for caution. Risk-factor assessment has shown that patients with unstable angina and poor myocardial function are at relatively greater risk" [source: Bhimji].

But even for those who have no complications, getting over the surgery takes time. Uncomfortable symptoms of CAD and angina -- such as severe chest pain -- may take up to three months to improve. A year after receiving TMLR, however, 80 to 90 percent of patients report a higher quality of life than before the surgery. Plus, their chances of having a heart attack are significantly reduced [source: Texas Heart Institute]. But since transmyocardial revascularization is a new kind of surgery, long-term effects are still unknown.

It's possible to prevent angina by lowering your risk for coronary artery disease. Don't smoke, and avoid second-hand smoke, too. Eat several servings of fruits and vegetables every day, maintain a low cholesterol level and get plenty of exercise -- at least 30 minutes of activity per day. Living a healthy life will greatly increase your likelihood of having a healthy heart, which will minimize your chances of needing any type of coronary-related revascularization surgery. They're impressive, groundbreaking procedures, but that doesn't mean you want to have one.