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Angina Pectoris (cont.)

Surgery

Like angioplasty, surgery is an option for people whose angina does not improve with medications and others who are at high risk of having a heart attack. Surgery is usually reserved for people with very severe narrowing or blockage in several coronary arteries.

In almost all cases, the operation used for severely narrowed coronary arteries is coronary artery bypass grafting.

Coronary Artery Bypass Surgery

The chest and rib cage are opened up (open heart surgery)
The narrowed part of the artery is bypassed by a piece of vein removed from the leg, or with a piece of artery behind the sternum (internal mammary artery), or a portion of the radial artery taken from the lower arm or forearm.
Several arteries can be bypassed in one operation.
This is a very safe operation, with a mortality rate of less than 1%, in people whose heart muscle is not severely damaged irreversibly and who have normal lungs, kidneys, liver, and other organs.
Because the chest is opened, the recovery time can be quite long, especially if the patient is older and has multiple other health problems.

Transmyocardial Revascularization

Transmyocardial revascularization is a procedure for people who cannot undergo angioplasty or surgery.

A simple incision is made in the chest, and a laser is used to "drill" small holes through the outside wall of the heart into the left ventricle.
About 20-40 holes are made.
Bleeding from these holes is minimal and usually stops after a few minutes of pressure.
It is not clear why this helps relieve angina. One theory is that it stimulates growth of new blood vessels that improve blood flow to the heart. Other investigators believe it is a placebo effect.

Current research is focusing on trying to find growth factors that could be injected into coronary arteries or directly into the left ventricle to encourage growth of new blood vessels.