When is it time for heart surgery?

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 circumstances

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.

The Physician

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
• Fainting
• 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.

The Patient

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 medical conditions
• 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 heart-lung machine.”

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 surgery.”

For more information on cardiac health and surgical options, talk with a physician at one of these locations or find a physician near you:

Alaska: Providence Heart & Vascular Center

California: Providence Saint John’s Health Center

Washington: Providence Regional Medical Center Everett

Oregon: Providence Heart & Vascular Institute

Montana: International Heart Institute

Kadlec: Kadlec Regional Medical Center