Surgical precision

Heart patients receive leading-edge treatment before, during and after surgery, providing them with a second chance for a more heart-healthy life

BY JOEL SCHLESINGER
Winnipeg Health Region
Wave Magazine, Summer 2010

Angie Sumka flashed a quick thumbs-up to her family as she was being wheeled on a gurney into the operating room.

"Don't worry. I'll be back," she remembers calling out as her friends, her mother Isabel, son Mitchell and daughter Shannon looked on with worry.

It was a Friday afternoon in the fall of 2008, and Sumka was about to undergo emergency double heart bypass surgery at the Winnipeg Health Region's Cardiac Sciences Program at St. Boniface Hospital. Just a few hours earlier, the 47-year-old businesswoman had arrived at the Bergen Cardiac Care Centre for an angiogram. She had been having some heart trouble, and doctors wanted to use the angiogram - a kind of X-ray of the heart - to take a closer look.

It's a good thing they did.

The angiogram revealed that Sumka's left coronary artery, the main blood vessel that feeds her left ventricular muscle, was 98 per cent blocked. The left ventricular muscle is the largest in the heart and is responsible for causing the left ventricle - the largest of the four chambers of the heart - to pump oxygenated blood throughout the body.

A blockage of this type is often referred to as the "widow-maker" because most people who suffer a heart attack as a result of it die instantly. In other words, Sumka was lucky to be alive.

There are essentially two ways to address blockages in arteries. One way is through a procedure known as angioplasty. This involves inserting a balloon through a catheter tube up through the femoral artery to the blockage in the artery. The balloon is then inflated with a special solution, opening up the artery and restoring blood flow. Around the outside of the balloon is a stent, a stainless steel piece of mesh that expands with the balloon and keeps open the artery after the balloon is deflated and removed.

The other way is open-heart surgery.

Because of the size of the blockage and its location, angioplasty was deemed too risky for Sumka. Doctors opted instead to schedule her for bypass surgery, and by noon that day she was being wheeled into the operating room for a double-bypass.

Despite the sudden turn of events, the Winnipeg woman remained optimistic.

"There was no point in being scared," she says. "'What has to be done, has to be done,' I thought to myself at the time. It's not like I can change my mind and get up off the table."

That's not to say Sumka wasn't nervous at the prospect of having a surgeon cut a sixinch incision in her chest and pull apart her breastbone to gain access to her heart. It's just that she knew she was in good hands with the staff working in the Winnipeg Health Region's Cardiac Sciences Program.

After all, the program carries out all major cardiac surgery in Manitoba, and offers patients comprehensive pre- and post-operative care. And new approaches in the operating room have led to a steady improvement in patient outcomes.

Dr. Alan Menkis is the Medical Director of the program. He says the improved outcomes for patients who undergo surgery can be attributed to advances in surgical technique and medical technology. But patient care has also changed dramatically. The Cardiac Sciences Program employs a model of care that emphasizes the need to give patients the treatment they need - from clot-busting drugs to open-heart surgery - as quickly as possible. Suitable patients are also selected into a "fast-track" model of post-operative recovery and return to normal activity.

"It's a process that started probably over 10 years ago," says Menkis. "It was an evolution of how we look after heart patients."

The "fast-track" model challenges longheld beliefs in certain protocols for surgery and aftercare that are not necessarily in the patients' best interests.

At one time, for example, patients spent days on a ventilator in the ICU following surgery. They were deliberately kept asleep on a breathing machine when they did not need to be. Instead, doctors found most patients could be woken up soon after surgery and start their rehabilitation immediately.

Over the last decade, Winnipeg has become a world leader in the fast-track model because health-care providers at the centre are constantly looking for ways to improve outcomes for patients as quickly and efficiently as possible.

"We've looked at patients who, for instance, will have surgery in the morning and who could go to the ward by the evening rather that stay in the intensive care unit overnight," says Menkis. "So if they could go to the ward in the evening, they could then be in a more normal environment and start their rehabilitation even sooner so they could be up standing beside the bed the same day as having surgery."

The "fast-track" model also features a comprehensive 24-hours-a-day, seven-daysa- week approach to cardiac care. The result is that about 1,300 surgical procedures are performed through the Cardiac Sciences Program annually and, despite the fact that patients are often very ill, the mortality rate is low, and getting lower each year.

"Twenty years ago, heart surgery was anything but routine," says Menkis, also a Professor of Surgery and Chair of Cardiac Surgery at the University of Manitoba. "Today, coronary bypass is amongst the most common operations done in the western world."

Sumka was a beneficiary of this new approach, along with other advances in surgical technique and expertise.

As the name suggests, bypass surgery involves rerouting oxygenated blood around a blockage in a coronary artery so it can flow to the heart muscle.

The first step in the procedure is to take a vein from the patient's leg or artery from the forearm to be used as the alternate conduit. In Sumka's case, one end of an artery was attached to the left anterior coronary artery, below the blockage, while the other end was attached to the subclavian artery.

The process of attaching the new vessel to the artery is called grafting. While this procedure is underway, the heart's role of pumping blood to the lungs to be oxygenated, back to the heart and then to the rest of the body is taken over by a pump oxygenator, also called a heart and lung machine.

Once the graft is complete, the blockage is bypassed and blood flow to the heart muscle is restored. With a fresh supply of oxygen-rich blood, the heart muscle can continue functioning as it should.

Bypass surgery has a very high survival rate. But 40 years ago, heart surgery was such a dangerous procedure that it was offered as a last resort.

"You would apply the surgery to people who were at imminent risk of dying because you could really only do benefit and not do more harm, and we were always concerned about the balance between risk and benefit," Menkis says.

But as techniques and technology improved, so did outcomes for patients. Today, it's no longer a question of whether the patient is sick enough to risk a bypass; it's a question of whether the patient will benefit in the relief of angina and increased lifespan.

And increasingly, even patients in the poorest of health can safely receive a bypass.

"Currently, (mortality rates) are approximately half the level of what was expected 15 to 20 years ago," says Dr. Darren Freed, Head of the Surgical Heart Failure Program. "This is in spite of the fact that we are operating on patients who are sicker, with a higher level of acuity."

The mortality risk for isolated bypass surgery is 1.18 per cent for patients of any age, whether it's an emergency or non-emergency procedure, Menkis says. "They're very good relative to everyone else, but we look upon it as though if it's 1.18, why isn't it 0.5, and how can we get it to there?"

Following surgery, Sumka embarked on a rehabilitation program that is really more of a life-long regimen to promote heart health than a six-month to one-year lifestyle overhaul.

Under the "fast-track" model, patients are often moved quickly from intensive care to the cardiac ward for recovery. This reduces the likelihood of infection, such as pneumonia, and increases the speed of recovery.

Patients often work with their surgeon, family practitioner, cardiologist, nurses, pharmacists and physiotherapists on the road to recovery. They even meet with psychologists and social workers, if required. Patients need well-rounded care throughout recovery or all the initial efforts and treatment are prone to fail.

For Sumka, the first stop on her path back to health involved working with a cardiac intensivist, a doctor who helped manage her condition in the hours after her surgery. An anesthetist also helped to reduce her pain in the hours and days following the procedure.

Her chest really hurt badly at first. "When they asked me how I felt, I said, "Like a truck ran over me.' It hurt," she recalls. "Immediately after surgery, with any coughing or movement, I could feel a clicking in my chest." Someone brought her a teddy bear to hold up against her chest when she coughed. "Anytime I had to laugh, I could put pressure on my chest so it didn't hurt so much."

Her recovery was speedy, a little less than the average stay of eight days for most patients at St. Boniface Hospital. By the following Thursday, she was released from hospital and sent home to recover. And three months later, she was back at work.

While her life went on very much as it did before the surgery, some aspects changed dramatically - for the better. "It changes the way you look at life," she says.

Sumka went for rehabilitation at the Wellness Institute at Seven Oaks Hospital, one of the city's two cardiac rehabilitation centres - the other being the Reh-Fit Centre on Taylor Avenue near Waverley Street.

At the institute, a cardiac rehabilitation therapist works with patients to find the right level of exercise appropriate for their recovering cardiovascular system. While the exercise must not be too strenuous to cause further problems, therapists also help patients overcome a fear that exercise will cause a heart attack.

As part of her recovery, Sumka has made adjustments to her lifestyle, but it hasn't always been easy, especially when it comes to work-related issues.

"When you have a heart attack and you go to all the rehab classes afterward, and you learn about what stress does . . . You don't realize when you're getting upset and frustrated over things that really shouldn't even be a second thought - and I'm still guilty of it - that it all adds up."

Sumka also worked with a dietitian, who provided her with a new way of looking at how she eats. She now reads labels on the food she buys. She studies the fat and salt content. She eats more fresh fruits and vegetables and less fatty foods - like cheeseburgers, french fries or fried chicken.

"I try to eat more vegetables and fruits than I used to. I don't use salt at all," she says. "My biggest thing is shrimp. I love it but it's so high in cholesterol."

Some patients have difficulty making long-term changes because the temptation to return to old habits is always there. "It's a bit of an uphill battle," says Menkis. "Our society is not geared for healthy living, and that makes it difficult." Fast food is everywhere. The reasons not to exercise after a stressful day at work often seem plentiful as opposed to the reason to get some exercise.

Freed says lifestyle changes are often the most difficult part of the entire treatment process. "The prognosis after surgery is very good, with the vast majority of patients returning to a normal lifestyle," he says.

Diet, exercise and stress reduction are large parts of the rehabilitation and educational process, and if patients can make the changes and sustain them, the likelihood of returning for further surgery or treatment is greatly reduced.

"I always stress to my patients that they have a chronic disease that they must never forget about," says Freed. "In general, those who dedicate themselves to a healthy lifestyle enjoy a longer-term result."

Joel Schlesinger is a Winnipeg writer

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	About Wave Wave is published six times a year by the Winnipeg Health Region in cooperation with the Winnipeg Free Press. It is available at newsstands, hospitals and clinics throughout Winnipeg, as well as McNally Robinson Books. Read the Summer 2010 issue of Wave