Surgery Treatment for End Stage Heart Disease: Frequently Asked Questions

What is end stage heart disease?
End Stage heart disease is heart disease of any origin that progressed to an end stage or an advanced form of that disease. Although the patient can be maintained on treatment, the patient is still sick, probably disabled, and generally unable to function at even limited levels of activity.
What determines when heart disease has reached the end stage?
Usually, the chronicity of the disease. For example, someone who has end stage ischemic heart disease has been suffering with that problem for many years. They will frequently have a history of multiple heart attacks and possibly surgical intervention.
Is heart disease hereditary, and if it is what can be done to lower risks?
The answer to that is really two questions. First of all, there are forms of heart disease that are hereditary. Secondly, there are forms of heart disease that are not hereditary. The speed with which the acquired heart disease develops can be related to the presence of risks factors. For example, patients who have ischemic heart disease where the blood supply to the heart has decreased - the rate at which this disease develops or progresses is influenced by many well-known risks factors. The patient can control some of these risks factors and some cannot. The risk factors that cannot be controlled are advancing in age, gender, and family history. The risk factors that can be controlled include such things as obesity, smoking, high-blood pressure, exercise or lack thereof, and so on.
Is there much hope for a patient with end stage heart disease? Should a patient at this stage of the disease consider cutting edge treatments if all else is not working out in their benefit?
That depends upon the primary disease. But in general, patients with heart disease should seek care provided by a specialist. The heart specialist can then recommend the appropriate therapy for the patient.
At what age do most people develop it? Does it affect more men or women?
That depends upon the disease. Again, there are a variety of different types of heart disease. Again, depending upon the primary disease state, it can occur in any age group. Usually heart failure and ischemic heart disease is associated with advancing in age.
What kind of role does diet play in preventing it?
Appropriate diet plays an important role in the prevention of ischemic heart disease. To lower the risk of ischemic heart disease, everyone should avoid foods that are high in fat content and cholesterol. Everyone should also attempt to avoid obesity by choosing an appropriate diet associated with an exercise program. And no one who wants to be healthy should smoke.
What does surgery entail? What is the approx recovery time?
There are many types of open-heart surgery, each of which has a different recovery time. As an example, the most common open-heart operation performed is coronary by-pass surgery for patients who have blockages in the arteries supplying blood to the heart. Depending upon the complexity of the operation, and the patient's pre-operative health status, the patient usually remains hospitalized 4-6 days after the operation. With appropriate rehabilitation, the patients are usually back to full activity within 6 to 12 weeks.
Who is the ideal candidate for surgery?
Again, that depends upon which operation is being performed. We look at a variety of pieces of information related to the function of the patient's heart, and other health related conditions in determining the patient's operative risk.
How many bypasses are possible through minimally invasive bypass surgery?
That number is increasing as experience with this operation has increased. Originally, access was limited to the front of the heart. Now even the vessels on the back of the heart can be by-passed without the use of the heart-lung machine.
What is the average life expectancy after bypass surgery?
That depends on the patient's age, the completeness of the by-pass operation, the patient's underlying heart function, and the patient's associated medical problems. In general, the by-pass operation will correct the patient's ischemia for 10 to 15 years. At that time, the angina may reoccur. If angina does reoccur, the patient’s candidacy for medical and surgical therapy is re-evaluated.
What makes a surgery "minimally invasive"?
Traditionally, open-heart surgery is performed with the patient connected to a machine known as the heart-lung machine. The heart -lung machine replaces the function of the patient's heart and lungs while the operation is performed. The patient's heart is stopped while we operate on it. Recently, there has been interest in performing heart by-pass surgery without the use of the heart-lung machine. In this instance, the patient's heart and lung continues to function while the operation is performed. The patient’s anatomy and the type of operation they require determine whether the heart-lung machine is employed. For some time, it was thought that such an approach would allow the operation to be performed through a smaller incision - hence the term, minimally invasive. In fact, most "op-pump" surgery is still being performed through the standard incision through the length of the breastbone.
Who is a candidate for a heart transplant?
Heart transplantation is usually offered to someone who has end-stage heart failure. Their heart problem is not correctable by any other operation, and the patient's must fulfill a number of selections and exclusion criteria. Examples of such criteria include: no irreversible kidney or liver failure; the patient is receiving appropriate heart failure therapy; and despite medical therapy has a limited life expectancy. The patients and their families are also appraised of what cardiac transplant entails including medication changes, the operative plan itself, and the need for close long-term follow-up. If the patient's physician believes the patient is a suitable candidate for heart transplantation and the patient has been appropriately educated, then the patient is offered this therapy. If the reader is particularly interested in heart transplantation, they might also check back to this site later today when Dr. Cadaret is online.
Are the veins taken from the leg during bypass surgery? If so, why?
The purpose of by-pass surgery is to improve blood flow to the heart muscle. The blockages in the artery supplying blood to the heart are not removed. Rather, blood is routed around the blocked areas in the arteries supplying blood to the heart. This entails the use of conduit. Conduits that are available are the veins from the leg, the saphenous vein, the artery from the inside of the chest wall called the internal mammary artery, and occasional an artery from the forearm, known as the radial artery.
What is the mortality rate following bypass surgery?
In general, the operative mortality is about 2 to 4 percent depending on the patient's heart function and other associated medical problems. If a patient had depressed heart function or other medical problems such as kidney failure requiring dialysis, the operative risk may be higher. In general, this is a relatively safe operation.
Do people experience swelling following a bypass?
Patients do develop swelling in the legs following coronary by-pass surgery, for two reasons: First, patients who are placed on the heart-lung machine will tend to retain water for a few days following the operation. Secondly, removal of the saphenous vein from the leg can lead to temporary swelling in that leg. That swelling usually resolves in a matter of a few months.
What foods/vitamins can help keep your heart healthy?
The best recommendation for diet is to avoid foods high in fat and cholesterol.
At what age are most people at risk for heart attack?
That depends on the patient's family history, and their risk factors. In general, older patients, in particular those who smoke, who are obese, who have elevated cholesterol, are at higher risk for heart attacks.
Is it safe for people to exercise after having bypass surgery?
Absolutely. However, the exercise program should be recommended and overseen by formal cardiac rehabilitation program. The purpose of by-pass surgery is to return the patient to as normal a lifestyle as possible.
What other surgeries do you perform for those with end stage heart disease?
We tailor the surgical therapy to the patient's cardiac condition. If the patient has end-stage heart disease related to problems with the heart valve, valve replacement or repair may be the appropriate operation for that patient. If the patient's heart failure is related to a lack of blood supply to the heart muscle, in selected cases, we may perform by-pass surgery. Any patient with heart failure not amendable to a standard cardiac operation may be offered cardiac transplantation. A promising form of therapy for patients with severe heart failure is a mechanical blood pump. Mechanical blood pumps are currently planted in patients who are awaiting a heart transplant, but who deteriorate prior to the availability of a donor heart. In this instance, a blood pump is inserted until a donor heart is available, at which time, the blood pump is removed, and the heart transplant is performed. As the number of patients who require a heart transplant exceeds the number of donor hearts that are available, it is anticipated that mechanical blood pumps will serve as a primary therapeutic modality for patients with end stage heart failure in the future.
Are people with end stage heart disease a candidate for cardiac rehab?
Yes. Again, it should be performed through a formal cardiac program.

Wayne Richenbacher, MD
Division of Cardiothoracic Surgery
University of Iowa Hospitals and Clinics

Peer Review Status: Internally Peer Reviewed

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