When the heart's arteries are blocked to a degree where it becomes difficult, sometimes even impossible, to continue normal activity, by-pass surgery may be recommended. In a by-pass operation additional arteries, usually made from leg veins, are used to detour (by-pass) around the blocked arteries. Usually the patient is able to gradually resume normal activities after a short recuperation period. This procedure doesn't open the blocked arteries, and it does nothing to reverse the build up of plaque which clogs the arteries. It only provides an alternate route for blood to reach the heart muscles. In many cases, surgery is the only choice when the blockage is so severe that the danger of heart failure is too great to try any other alternative. For such people, the operation is truly a life saver. For a great many others, there may be other alternatives.

Physicians and surgeons have seen the improvement that by-pass surgery offers many patients. They have also seen patients opt for lifestyle changes that include serious dietary changes and aerobic exercise, only to watch these patients gradually lapse back to their old eating habits and sedentary ways. Sooner or later such lapses result in the need for surgery, if a heart attack does not come first. A doctor may press for an operation because the outcome of surgery is more certain than promises and good intentions. If by-pass surgery has been recommended, it may be the only reasonable choice, but in many cases, such as mine, there may be options available that are not as drastic. Following lifestyle recommendations such as those in this book may bring about a reversal of coronary artery blockage. Before making a final decision, I recommend that you read Dr. Ornish's Reversing Heart Disease book and discuss his suggested alternatives with your doctors and family.

Although surgeons and hospitals have slight variations in their procedures, the typical by pass operation will start in the morning with the patient being given a tranquilizer to help bring down the anxiety usually found before any operation. Local anesthesia is given and intravenous (IV) feeds are inserted in the arm or wrist to allow the administration of fluids, medications and anesthesia. Other IV lines are used to measure oxygen, pressure and to place medications directly into the heart. A special catheter will be placed in a neck vein and pushed down into the heart to provide measures of heart function through pressure and temperature. Another catheter will be placed into the bladder to measure kidney function and blood supply. A combination of drugs is fed into the IV, to relax muscles, make the patient drowsy, (which prevents the patient from suddenly moving during the operation) and to block pain. Two tubes are inserted down the throat, one into the windpipe connected to the respirator to take over the job of breathing, and the other to collect stomach fluids and prevent nausea. An anticoagulant drug, such as heparin, is given to help prevent clots and strokes. At the end of the operation, a drug will be given to reverse the effect of the anticoagulant.

When the surgeons are ready to open the chest, an incision is made down the sternum (the midline of the breastbone) and retractors slowly separate the chest opening, revealing the lungs and the pericardium, the tough sac that protects the heart. While this is being done, another surgical team is removing sections of vein, each about 8 inches long, from a leg. The heart sac is opened and the heart-lung machine is connected. When the heart-lung machine has taken over the pumping and oxygenation, the by-pass procedure begins.

The aorta is clamped shut and the heart is stopped and then cooled. For each of the arteries to be by-passed, a hole is made in the aorta and one end of the leg vein is attached to the aorta. The other end is connected to a place below the blockage in the coronary artery. In some cases, the internal mammary artery, just above the aorta, is used as the source of the by-pass supply. When the by-passes are completed, the heart is gradually returned to normal temperature and the aorta is unclamped. At this point the heart either starts on its own, or an electrical shock is given to start it again. As the heart begins to circulate the blood on its own, the heart-lung machine is disconnected. Before the chest is closed, the surgeons see if the splices are sealed and there is no bleeding.

More than half a million by-pass operations are performed every year in the U.S. alone. Of these, many patents will become candidates for a second, and sometimes a third by-pass operation. It is important to understand that the original cause of the problem is not changed by this surgery. If lifestyle patterns that fostered the problem are not changed, coronary artery disease will continue to threaten the patient's life.

In McDougall's Medicine, A Challenging Second Opinion, a comparison of the risks and benefits of angioplasty, by-pass surgery and lifesyle changes is given. Some of the factors, updated since this book was published, are:

Factor	Lifestyle	Angioplasty	By-Pass
Early artery reclosure	none	30%	20%
Atherosclerosis stopped, slowed or reversed	yes	no	no
Brain Dysfunction	none	none	15%
Blood Transfusions	none	none	likely
Complications (during)	none	5%	5%
Death (elderly, during)	none	1%	2%
Cost (1995) in $	none	10,000- 35,000	50,000- 80,000

In addition to the cost of the operations, time off work, stress to the family, and risk factors also need to be considered.

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