Once scary, bypass surgery has become common, safer
Frank Vignuli couldn’t be having a heart attack, could he? He wasn’t short of breath. His chest didn’t feel tight. But on the morning of Aug. 4, 2004, the 47-year-old from Wilmington, Del., didn’t feel normal. His jaw was burning, his shoulder was in pain. But he didn’t want to wake up his family. The port operations manager wasn’t in the habit of going to the doctor or asking for help about his health.
Finally, concerned about the ongoing sensation in his jaw, Vignuli woke his wife. Soon, he was in an emergency room, where a doctor told him he had just had a heart attack and needed quadruple bypass surgery immediately.
Hours later, he awoke in the cardiac intensive care unit at Christiana Hospital in Newark, Del. Since then, Vignuli has lived a successful and active life once thought impossible for people with clogged arteries, which can lead to stroke, infections and heart attacks.
He has done so thanks to a procedure once considered risky: More than 9 percent of the first 150 patients to receive the procedure at one hospital in 1966 and 1967 died before they were able to be sent home. That figure went down to 3 percent in 1999 for a large comparable group of American and Canadian patients. Today, 14 years after Vignuli’s surgery, deaths before being discharged from the hospital are between 1 and 3 percent, and surgeons have refined the procedure— and the rehab that follows—even more.
Coronary artery bypass graft surgery—or CABG, pronounced “cabbage”—is one of the best known, most studied and most effective surgeries of the modern age. “It’s a very safe operation,” says Timothy Gardner, past president of the American Heart Association. Gardner, former head of heart surgery for the University of Pennsylvania Health System, has performed thousands of CABG procedures.
People with coronary heart disease sometimes experience buildups of plaque—a combination of fat, calcium, cholesterol and other cellular junk—on the insides of their arteries. This can restrict blood flow and cause clots.
The most common symptom of a clogged artery is chest pain. Other symptoms include weakness, heart palpitations, sweating and nausea. A famous recipient of a quadruple bypass, former president Bill Clinton, experienced some of those symptoms before undergoing an emergency bypass surgery 14 years ago.
During bypass surgery, doctors graft a new artery or vein onto the heart, creating a channel through which blood can flow around the blockage. To do that, surgeons remove a vein from the leg, open the chest cavity, prep the heart, stop it with the help of a heart-lung machine to keep blood circulating, sew in the graft and kick the heart into action once more. Increasingly, “off-pump” procedures allow the surgery to be performed with a beating heart instead of relying on the heart-lung machine.
Once an oxygen-rich blood flow is reestablished to the heart muscle, patients with coronary heart disease can experience less chest pain, achieve a better quality of life and reduce the risk of heart attack. In cases where three or more arteries are bypassed, patients can survive longer than if they had other therapies.
The procedure is newer than you might think. Coronary artery bypass grafts were first described in 1910 by Alexis Carrel, a French surgeon, who made an unsuccessful attempt on a dog.
It would take 50 more years for the surgery to succeed in a human.
In 1960, a team of surgeons in New York led by Robert Goetz performed the first successful clinical coronary artery bypass surgery, piggybacking off experimental procedures perfected in dogs during the 1950s. The patient, a 38-year-old cabdriver, who was taking up to 90 nitroglycerin pills daily for severe chest pain, lived for more than a year after the procedure. “Our medical colleagues were not impressed,” Goetz recalled later in a letter. “To express it mildly, they were against the surgery in general and definitely against the procedure they considered not only highly experimental, but also unwarranted.” Despite the success of the procedure, Goetz’s fellow surgeons took a conservative view and refused to help move it forward. It was the only such procedure Goetz ever performed.
But his work inspired other surgeons, who began to perfect the technique. In 1967, René Favaloro, an Argentine surgeon working at the Cleveland Clinic, perfected bypass grafting—the procedure by which a vein or artery taken from the patient’s leg is connected just above or below the artery blockage to bypass the clog. His technique is still used today.
After that, CABG rose in popularity, becoming one of the most common weapons against a rising tide of heart disease. In 1968, Favaloro’s team had performed CABG procedures in just 171 patients. By 1979, 112,000 procedures were performed in that year alone. By 2000, that number had reached a peak of about 519,000 procedures a year in the United States.
“It has evolved and improved every decade,” Gardner says. Over the years, surgeons have continually gotten better at the complex dance of the two-to-three-hour procedure.
What once was an unthinkably complicated procedure has become common: About 213,700 Americans have a CABG procedure every year, down from its peak. The decline is due in part to the growing popularity of stenting, which was introduced in 1977. That procedure, in which small tubes are inserted inside the clogged or narrowed artery to keep it open, doesn’t require open-heart surgery.
There are risks associated with CABG: Around 2 percent of patients experience strokes after surgery, and some patients develop brain injuries or cognitive dysfunction. However, the incidence of stroke has fallen over the last 30 years.
Life expectancy after surgery has not. Ninety percent of a group of 1,324 patients operated on between 1972 and 1984 survived five years after surgery, according to one study, and 74 percent survived 10 years. That number has remained relatively stable ever since. However, older and sicker patients are getting bypass surgery these days, which may affect survival rates. Meanwhile, the time patients spend in the hospital after surgery has fallen to about seven days from about 12 to 15 days in the 1980s. “A well-done operation—especially for a patient on the younger side of the spectrum—is really the most effective and reliable treatment for coronary disease,” Gardner says.
Bypass surgery can add years to patients’ lives, and for Gardner, some of its biggest successes come to patients who embrace its lessons. “If they are able to dial up secondary prevention measures—for example, to stop smoking, to lose weight, manage their blood pressure, live hearthealthy lives—they can have very good long-term outcomes,” he says.
That’s what happened to Vignuli. He’s 61 years old now and says his bypass was a wake-up call. After the procedure, he participated in cardiac rehabilitation and followed his doctors’ suggestions.
“I was 47, but I ate like a 14-yearold,” he says. “I’ve upped it to a 21-year-old now.” He eats healthier foods, has addressed his sleep apnea and has tackled his job-related stress. Today, his life expectancy is considered to be normal by his cardiologists, he said, and his heart has recovered from the scarring caused by the heart attack. Most of all, he has learned to tune in to his body— and go to the doctor if something feels off.
“I wish I had taken better care of myself,” he says. “But I bounced back.”