The Heart Of The Matter: Bypass Surgery

After his third heart attack, William Lewis faced the risks of a coronary bypass.

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When a company is running smoothly, the owner doesn't usually worry about its continued existence. But William C. Lewis was having plenty of anxiety about the future of his tiny but thriving company because it depended on his own survival, which was very much in doubt. After three heart attacks, the owner of the Lewis Flag & Banner Co., a manufacturer of specialty flags in Boston, had to decide if he would let doctors open his chest for coronary bypass surgery.

In high school, William Lewis had been captain of the football, basketball, and track teams. Now he could hardly make it across the street. He felt tired almost all the time. "Life was dragging," he remembers. "I was functional, but that's all. If I walked any distance, I'd have to stop. It's not that I was having sharp pain. It was like gas or pressure in my chest, like having two hands pushing against it, and I felt it even when I was relaxed."

Chest pain, or angina pectoris, is the heart's way of complaining about not getting enough oxygen-laden blood. A heart attack (myocardial infarction) signals that chunks of cardiac tissue are actually dying for lack of blood. If the amount of heart muscle that dies is large enough to make the heart pump inefficiently or quit altogether, the patient dies. That happens to more than a third of the 1.5 million people a year in the United States who have heart attacks.

Lewis's doctors had suggested a series of tests to see how well his heart was functioning and to check the condition of his coronary arteries, the vessels that carry the heart's blood supply. After evaluating the results, they advised surgery.

It was no easy decision for Lewis, then 53, during that precarious period nearly four years ago. He knew from his doctors that most patients feel a lot better after the operation because the often disabling pain is relieved. But he didn't have any hard facts on how much longer patients live or whether they can pick up their businesses and their personal lives where they left off. And then there was the risk of dying. Heart specialists estimate the average operative death rate at less than 3% and the risk of a fatal heart attack during or soon after surgery at 5% to 10%.

When Lewis had to face these possibilities, he was lying in a bed at Massachusetts General Hospital recovering from his third heart attack in only three years. He had hoped he wouldn't need surgery, but his doctors told him they didn't think drugs alone would do the job anymore. Lewis decided that surgery was the only real alternative he had, other than just sitting in a chair for the rest of his life and never moving.

It was a wise decision. While he was waiting for a hospital bed to become available, he had a fourth heart attack, and was moved to the front of the line. Fortunately, none of the previous attacks had caused massive damage that might have made him ineligible for the operation.

In the typical coronary bypass operation, surgeons reroute blood around the parts of the coronary arteries that have become clogged, usually by fatty materials that build inward from the arterial walls and block the vessel's channel. The "pipe" they use to make the detour is most commonly a length of vein taken from the patient's leg.

After the heart has been stopped and the patient's circulatory system hooked up to a heart-lung machine, the surgeons start the actual bypass procedure. They connect one end of the vein graft to the aorta, the large artery rising out of the heart's main pumping chamber, and the other to the diseased coronary artery at a point downstream from the obstruction. Depending on how many of the coronary arteries have narrowed or closed and where the trouble is located, a patient could get as many as nine bypass grafts. In Lewis's case, only three were needed.

When he woke up in Mass. General's intensive care unit that day in April 1977, Lewis was "just really glad to be alive, and that it was over." Two or three days later, he was walking in the hospital corridors. About 12 days after the surgery -- "the same as when I had my heart attack" -- he was home. After about six weeks, he was back on the job. (The more typical convalescing period is two to three months.)

"I started right in again," Lewis says. "But although I was able to take over almost immediately, I was leery of overexerting myself. Even so, I was driving and walking. I felt great. It was almost a rejuvenation."

Cardiologists currently recommend bypass surgery mainly for people disabled by chest pain that drugs can't relieve. About 90% of bypass patients do indeed live and feel much better because they're relieved of the severe angina. How much longer they live seems to depend mostly on which and how many of the coronary arteries are blocked, and on whether the damage the heart may have sustained from reduced blood flow affects its ability to pump.

When doctors recommend bypass, they generally try to make partients understand that relief of pain does not mean the disease that caused the arterial obstruction has been cured. It will continue, though more slowly, and may cause new obstructions if the patient doesn't cut down on risk factors that probably contributed to the original problem. These include cigarette smoking, obesity, uncontrolled hypertension, and a high-fat diet.

Another possibility after surgery is that the vein graft itself may close up, as it does within a year in 10% to 15% of cases. Moreover, the chest pain may come back five to seven years after the operation in about 50% of patients, and the percentage increases each year after that.

Though Lewis didn't have any of the risk factors and though he felt and looked great, he had a fifth heart attack a little more than three years after the surgery. He says his doctors found no evidence of coronary artery blockage or anything specific to account for the new attack. They attributed it to stress. He recovered quickly, as he had from his previous heart attacks, and he's working the way he did before he had heart disease: "a full 8 hours, and 10 or 12 when I need to." On and off the job he recommends bypass surgery to anyone who asks. The askers include a great many businesspeople.

When Lewis talks with businesspeople who are trying to decide whether to have the operation, they express many deep concerns and contradictory feelings. Foremost is the fear of dying, followed closely by fear of being disabled or severely limited in their activities. And while they want desperately to be able to function as they did before their hearts went bad, they are reluctant to take the time off to have the surgery. "They worry that something will happen to the business," says Lewis.

Lewis has also observed a sense of inadequacy in businesspeople with serious heart disease. They confide that because doctors have ordered them to avoid stress and exertion, they have begun to feel useless. Where they used to feel important, in their own companies, they now feel unimportant. These concerns often persist even after bypass surgery, Lewis says, "but you find out there's no reason for them. You can take charge and do things again, but it all comes back slowly." Reflecting on his own experiences, says Lewis, "I feel lucky."