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Heart Repair: Bypass or Angioplasty?

When it comes to heart surgery options, it's never one size fits all

by: Dr. Mehmet Oz | from: AARP The Magazine | Jan./Feb. 2011 issue

Dr. Mehmet Oz — Photo by Art Streiber

En español | The majesty of the heart is not lost on poets — nor on heart surgeons. I have seen the heart curl out of the chest like a python ready to strike, and watched it timidly collapse in failure, a condition that kills 300,000 Americans every year.

Yet despite everything we know about the heart, we still have much to learn. Two new studies in particular have challenged our commonly accepted standards for treating heart disease. Their results surprised even me.

For many years surgeons treated coronary artery disease — the buildup of plaque in the arteries — with a coronary artery bypass graft (or CABG, often pronounced "cabbage") procedure. A CABG involves harvesting a healthy blood vessel from your leg or chest wall and using it to bypass the plaque-filled section of the artery.

Two methods emerged in the 1980s and 1990s that gave patients alternatives to risky, invasive bypass surgery — balloon angioplasty and coronary artery stenting. In balloon angioplasty, a catheter carrying a small balloon is threaded into a clogged artery and inflated, pushing the plaque against the artery wall and reopening the artery. In stenting, a tiny, scaffoldlike mesh tube is threaded into the artery during angioplasty, then deployed like a tunnel support.

Heart Surgery by the Numbers

Total Procedures Per Year

Angioplasty with balloons or stents (PCI procedure): 1.3 million

Bypass surgery (CABG): 448,000

Mean Cost

PCI procedure: $51,445

Bypass: $112,377

Since the introduction of these alternate approaches (known as PCI procedures), their use has soared and today eclipses that of bypass.

Few studies, however, have compared these procedures against bypass, until now. One study looked at the mortality associated with bypass versus PCI procedures. It found that patients with multivessel disease who were 65 and older and those with diabetes had a lower mortality risk from bypass surgery. Patients younger than 55 fared slightly better with PCI procedures.

The second study looked at the health risks associated with bypass versus stenting. Higher risk patients who got stents were more likely to suffer a heart attack or stroke within three years, and more likely to require a repeat procedure. Low-risk patients fared equally well with bypass and stents.

The results of these studies illuminate an important facet of medicine: No procedure is one size fits all. I discuss with my patients their unique situation, and we reach a decision together. These new findings are something that all heart surgeons, including myself, will be taking into account. You should, too.