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Susan Goodreds never thought she'd need coronary artery bypass surgery. She had always eaten a healthy diet, never smoked, and had been an athlete all her life. She ran a ski shop in Goshen, New York, for 23 years and had skied all over the world. "I ran 10k races, I played golf, I played tennis, I swam with dolphins," she says. Despite a family history of heart disease -- a problem she assumed was more of a concern to the men in her family -- and a little mild chest pressure from time to time that she attributed to stress, Goodreds, 61, never suspected that she was a heart attack waiting to happen.
Then, several years ago, she learned that her cholesterol was high. But when it didn't respond to several different statin drugs despite her healthy lifestyle, she grew worried. Thanks to information she'd gained from working with the American Heart Association, she went to her doctor and demanded a C-reactive protein test and a heart scan. Her scan showed that she had plaque clogging her coronary arteries, so in January 2003 she underwent cardiac catheterization, in which a scope was inserted into her heart to take a look. The result? Despite having almost no symptoms at all, Goodreds had two coronary arteries that were 90 percent blocked. One of them was the left anterior descending (LAD), the major artery of the heart often called the "widowmaker" in a lingering bit of gender-biased terminology. It likely would have caused her to die if it had closed up completely. Because of the location of the blockages, Goodreds was not a good candidate for an angioplasty, in which a cardiologist threads a catheter into an artery in the leg, up to the aorta, and into the narrowed or blocked artery and inflates a balloon and/or places a stent to keep the artery open. So she would need bypass surgery, also known as coronary artery bypass graft (CABG and, yes, pronounced like the vegetable).
Goodreds was scared, and she didn't want just any heart surgeon to operate on her. Since she now worked as a healthcare marketer, she was a believer in researching doctors and treatments. She sought out Mehmet Oz, MD, for his renown as director of the Cardiovascular Institute at Columbia University-New York Presbyterian Hospital, in New York City, and his state-of-the-art skills. But she was also intrigued by the 43-year-old's reputation for addressing the mind-body connection in healing, especially in women, as founder and medical director of the Integrative Medicine Program at Columbia Presbyterian Medical Center, one of the top medical research institutions in the world.
Dr. Oz often speaks at medical conferences about how different women's hearts are from men's. Goodreds, even with a major blockage that was detectable on a scan, had gone undiagnosed for years due to lack of major symptoms. And some women's arteries may have no detectable plaque at all but may close up from spasm, or a temporary constriction, sometimes even to the point of triggering a heart attack. Although it's not known what causes these spasms, which happen more often in women than men, many doctors believe that fluctuations in estrogen levels contribute, and stress may play a role, too. And it also makes women's heart disease more problematic to treat. "If a man has a blockage," Dr. Oz says, "you can ream it out with angioplasty or put a bypass over it, and it's easy. But in the woman, the problem is more diffuse. How do you bypass a spasm? Technically, it's more difficult."
This difference between men's and women's heart disease may partly explain why women are still underdiagnosed and undertreated, even though about the same number of women die each year of coronary artery disease (CAD) as men. In 2001, for example, 689,000 men had removal of a coronary artery obstruction with angioplasty or insertion of a stent, according to the Centers for Disease Control and Prevention, while only 363,000 women did. Similarly, 365,000 men had CABG, while only 151,000 women did.
"The question of whether there is bias against women in heart treatment has been around for some time, and in fact our data do show a bias against giving women more aggressive therapy," says Sujoya Dey, MD, a cardiologist at the University of Michigan Cardiovascular Center. A recent study, presented at the American Heart Association conference in November, showed that women who suffer chest pain or a heart attack have milder and more diffuse blockages in their major arteries than men. "But our findings also suggest that a small part of the difference in treatment may be understandable, because women's CAD appears to be different, sometimes occurring in vessels too small for angiography, angioplasty, or bypass."
"Despite these findings, the major percentage of bias against women and the lack of aggressive treatment when they have heart disease still remains to be explained," says Marianne Legato, MD, professor of clinical medicine at Columbia University College of Physicians and Surgeons and the founder and director of the Partnership for Gender-Specific Medicine at Columbia University, in New York City. "And it's not because women refuse care or treatment. That only accounts for 3 to 6 percent of the difference."
Women who do undergo heart surgery don't do as well afterward, either, says Viola Vaccarino, MD, a cardiovascular epidemiologist at Emory University, in Atlanta. Women, particularly younger women, have as much as three times the risk of dying during or shortly after CABG than men do, she reported in a 2002 study in Circulation: Journal of the American Heart Association. And women have a more difficult recovery than men after CABG, too, including more symptoms of anxiety and depression and a higher rate of infections and readmittance to the hospital for heart failure, according to her 2003 study published in the Journal of the American College of Cardiology. Dr. Oz says women often have more advanced conditions by the time they're referred to a surgeon, "perhaps because they were not evaluated aggressively enough in the beginning."
But the news is not all bad for women with CAD, says Dr. Oz. If angioplasty isn't possible for you and surgery is indicated, there are amazing new surgical techniques that are less invasive than previous techniques, cause less pain, and may allow faster, and better, recovery.
To create a bypass, the surgeon removes a vein from the leg or an artery from the chest and attaches one end to the aorta, the huge artery at the top of the heart that carries blood to the rest of the body. The other end is attached to the coronary artery below the point where it's clogged, thus rerouting the blood flow so it bypasses the narrowed or blocked area. The number you sometimes hear with this surgery, as in "double bypass" or "quadruple bypass," refers to the number of arteries that get a rescue graft. This surgery has traditionally been done with the heart shut down while a heart-lung machine takes over the blood-circulating duties.
Surgeons have long noted that some patients become confused, forgetful, and even have short-term personality changes (sometimes referred to by surgeons as "pumphead") after undergoing CABG while on the heart-lung machine. It has been estimated, Dr. Oz says, that as many as 20 percent of patients have some short-term cognitive defects, about 6 percent of them serious. This may happen because the microscopic debris and irregular blood flow from the pump may plug tiny blood vessels in the brain and short-circuit the connections between brain cells. It seemed logical, therefore, that keeping the heart beating during surgery would eliminate the problem.
So a few years ago, an exciting new way of doing the surgery "off pump" was developed, in which the surgeon does the operation while the heart is beating, with no need for the heart-lung machine. Last year about 23 percent of all bypass surgeries were done off pump, according to the Society of Thoracic Surgeons' national cardiac database. (Goodreds had this surgery.) Dr. Oz says that, understandably, it's a little more difficult to operate on a slippery, beating heart than a still one. But once learned, it's a quick and efficient procedure that is less traumatic to patients' bodies. Patients bleed less, says Dr. Oz, and they have less risk of heart attack during surgery.
Still, off-pump surgery has not yet been proven in studies to provide a major benefit in the incidence of short-term cognitive problems. "I think that in some categories it is better, in older patients with hardened arteries, for example, and in people who have had prior strokes," says Dr. Oz, who is now performing off-pump surgery in about one-third of his bypass cases. For now, both techniques are viable, but questions remain. The answers may become clearer in 2007, when a large ongoing study by the Department of Veterans Affairs will be finished.
Until then, says Eric Peterson, MD, associate professor of cardiology at Duke University School of Medicine, in Durham, North Carolina, "If you're going to have off-pump surgery, go to someone experienced. There is a learning curve for surgeons -- it's a technical challenge. But once they're good at off-pump surgery, the outcomes can be excellent as well."
Goodreds sailed through her off-pump, double-bypass surgery in March, 2003. "I did not have any noticeable memory loss or confusion afterward," says Goodreds. "But then, I didn't expect to!"
Just a decade ago, a surgeon performing heart surgery had to make a large vertical incision down the entire length of the patient's breastbone, then break the sternum in half and push it out of the way to get to the heart. Now there are several less invasive ways to access the heart, and Dr. Oz helped pioneer these techniques at Columbia (in fact, he wrote the award-winning textbook Minimally Invasive Cardiac Surgery, in 1999). For example, surgery on heart valves, holes in the heart, and even some CABGs can be performed by making a relatively small, three-inch incision under the breast and pushing the ribs out of the way to get at the heart without breaking any bones. These mini incisions allow for quicker recovery and, especially in women, a scar that can be completely hidden under the breast. They also cause less chronic pain than having the chest bone broken, which can ache for months or even years afterward. With no big muscles or bones cut in this procedure, the pain doesn't last for more than a few days. The technique is not more difficult to perform, Dr. Oz says, but still, "many surgeons won't do that operation, because they have to break their old habits and relearn what they know. It's like when you had to stop writing longhand and start typing on the computer. Shifts are required."
The reluctance of some doctors to change may be understandable, though. If a surgeon knows how to perform a surgery safely a certain way, he may just want to keep doing it that way. Not all surgeons want to learn the newest techniques, though it is an option for anyone who wants to learn. Minimally invasive cardiac surgery training is available at most major U.S. academic medical centers.
Another advance in minimally invasive surgery now widely performed during CABG is good news to many women: a better way of harvesting the vein from the leg to use in the bypass. Just a few years ago, the veins were removed by making a long scar the entire length of the leg. These unsightly incisions were also extremely painful to heal from. But now the veins can be removed endoscopically, with just a small puncture, using an instrument that snakes under the skin, frees up the vein, and allows the surgeon to pull it out. This reduces pain as well as the rate of infection. "And not having a scar on their legs is especially important to women," Dr. Oz says. "Some men barely seem to notice."
Robots in the O.R.An exciting and even less invasive option for heart surgery is robotics. These tiny, high-tech instruments can be used to bypass blocked arteries, fix heart holes, and repair mitral valves. Michael Argenziano, MD, 37, director of minimally invasive and robotic cardiac surgery at New York Presbyterian Hospital, in New York City, and a protege of Dr. Oz, has been a pioneer in its development. "Robotic surgery is less traumatic, cosmetically superior, and allows for much faster recovery," he says. And, since women are proportionally more traumatized by conventional open-heart surgery (the same size cut is needed to open a woman's chest as a man's in order for surgeons to get their hands inside), this is very good news for women.
During a procedure, the surgeon inserts robotic arms through three or four small holes between ribs on either the right or left side of the chest, depending on the part of the heart requiring surgery. On the tips of the arms are a bright light and a three-dimensional camera to transmit the image to a console, as well as surgical instruments such as tweezers, scissors, and knives. Then the surgeon maneuvers the robotic arms from a seat in front of the console away from the patient. Monitors can be placed around the room so everyone can see the surgery clearly in magnified color. One of the nice things about the robotic systems, Dr. Oz says, is that they can enhance a surgeon's skills. "I can adjust the machine so that any tremor I might have disappears," he says. "It has greater precision, as well as a safety mechanism so I can't accidentally push it where it shouldn't go."
"Although the device costs about $1 million, this is definitely part of the future," says Dr. Argenziano. Robotic systems are not yet widely available, but Dr. Oz predicts they will be soon as more surgeons learn to use them. "Over the next two years," he says, "the knowledge will spread, and there will be very well-trained surgeons in every major metropolitan area who can use them."
Originally published in Ladies' Home Journal magazine, March 2004.