• Angioplasty and "Interventional" Cardiology
• Coronary Artery Bypass Grafting surgery

In these techniques, a special catheter is positioned via the arteries and the aorta, into a coronary artery that is partially or completely blocked by atherosclerosis, thrombus (blood clot), or both. In "angioplasty", the special catheter has a deflated balloon on the end. This balloon is positioned so that it crosses the blockage. The balloon is then inflated, forcing the blockage open.

While these techniques offer the hope of improvement in the disease process and sometimes of freedom from most heart medicines, they are not perfect. The main problem is "restenosis": the blockages close down again over a period of weeks to months. With most techniques, about 20-50% of the blockages undergo restenosis. Usually, the process is slow and the person does not suffer a heart attack. Sometimes, however, the blockage returns quickly and a heart attack can follow. Also, during the procedure itself, the artery can close completely and can be treated only by emergency bypass grafting surgery. Emergency surgery carries a higher mortality, of course.

For these reasons, the decision of whether to perform an interventional technique and, if so, which one, should be left to a qualified cardiologist. These techniques are wonderful for most people who have them. The complications, however, can be quite serious.

This type of surgery is now routine, and can be performed safely even in patients older than 80 years. Good results, with mortality less than 1-3%, do require considerable training and experience.

The larger question is, who should undergo this surgery? The answer is clear in some cases. For example, people who have had a heart attack and who have blockages in all three of the coronary arteries, live longer if they have bypass grafting surgery than if they are treated with medications. The same is true for people who have a blockage in the "left main" coronary artery, which divides into the two arteries that feed most of the left ventricle. It is equally clear that people who have blockages only in one coronary artery (except the left main) should not have bypass grafting surgery unless they have angina that cannot be controlled any other way. The question of what people should do when they have blockages only in two of the three coronary arteries is still controversial. The advice of a skilled cardiologist is often helpful. (If you ask two, you may get two different opinions!)

Some people cannot have bypass grafting surgery because their heart muscle is too weak or because they are otherwise too sick. There are two important points to remember about this fact:

• One surgeon's "high risk" patient is another surgeon's routine patient. If you really want to know, do ask several surgeons to make sure that you or your loved one really cannot undergo surgery safely.
• Many people believe that their doctor told them they "could not have surgery" when, in fact, the doctor said that they "did not need surgery now". This is a very important difference. The second statement merely means that the blockages aren't bad enough to justify the risks of bypass surgery. In such cases, the people are often excellent candidates for surgery if they ever need it. So don't lose hope unless you are sure of what is being said (and, even then, be sure to get another opinion in case the first doctor is a chicken).