Bypass Surgery and Higher Risk Elderly Patients

The Wall Street Journal issue of March 15, 2000, had a terrific article written by Thomas M. Burton entitled "For Failing Hearts, Doctors Synchronize Left, Right Ventricles". The article discusses a promising new treatment in dealing with congestive heart failure. The treatment involves implanting a device under the skin in the shoulder area of an electronic device that synchronizes the beating of the right and left ventricles. When the left and right ventricles are out of rhythm, blood sloshes back and forth uselessly within the heart. The implantation is usually done in the doctor's office on an outpatient basis, and takes place little more than an hour to perform.

The procedure has been successfully tested in Europe and Canada and is just making its appearance in this country now. The procedure is only for those individuals that have the electrical conductivity problem. It is obviously much simpler to perform the implantation rather than have a patient undergo a heart replacement operation. The director of the heart-failure program at the University of Cincinnati Hospital is William T. Abraham, which is one of the sites where the trials are being conducted in the U.S. There are 3 companies seeking regulatory approval for the device in this country. They are Medtronic Ind., Guidant Corp. and St. Jude Medical Inc.

Ever since 1990 the New York State Department of Health has published annual profiles of surgeons performing coronary artery bypass surgery. These profiles are called "cardiovascular scorecards". It was originally feared that surgeons would want to maintain high scores and thus avoid high-risk patients being considered for coronary bypass surgery. Many thought that these high-risk patients would be sent to other states for the operation so that the high score for New York State hospitals could be maintained.

A recent study showed that this has not happened. Elizabeth R. DeLong, Ph.D, led the study along with Eric D. Peterson, M.D., M.P.H., F.A.C.C.,of the Duke University Medical Center. Even though an increasing number of bypass patients with higher preoperative risk profiles has occurred, bypass surgery outcomes in New York improved significantly over the national average.

Between 1987 and 1992, 30-day mortality rates, unadjusted for patient risk factors, declined by 33 % in New York Medicare compared with 19% decline nationwide. Now this period therefore includes a period of time before the "scorecards" went into effect, but still it is meaningful. In this same period of time bypass surgery for New York residents out of State declined from 12.5% to ll.3%. New York State was the State with the lowest risk-adjusted bypass mortality of any State in 1992.

Other studies have shown that the chances for survival from coronary bypass surgery increase with the frequency that both the surgeon and the hospital where the surgery is performed do the procedure.

The harder question to answer is it worth the risk when you have an elderly person involved in the surgery? Will the "quality of life" of the patient be improved by the procedure? We are not even considering the costs involved since we are looking at lifestyle before even looking at costs. Is it worth the pain and suffering that the patient will undergo if the "quality of life" will not be improved that much. Again we are not attempting to answer this since only the family and close friends of the patient should be the ones, in conjunction with the patient to answer that question.



Allan Rubin
Updated March 15, 2000

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