How does a doctor decide which heart surgery to perform on a patient with multiple blocked arteries?

How does a doctor decide which heart surgery to perform on a patient with multiple blocked arteries?

DEAR DOCTOR :
When a patient has one or more blocked coronary arteries, how does a doctor decide whether to perform an angioplasty or bypass surgery?
DEAR READER:
Let me explain how your heart works before I answer your question. Your heart doesn’t just pump blood — it needs blood to survive. Every organ in your body needs a constant energy supply. And every organ is making waste material and needs a “garbage collector” to take the waste away. Both the energy supply and the waste removal come from the blood that constantly runs through every organ. The heart is the muscle that constantly pumps blood through every organ in your body.
Like any organ, the heart also needs energy and waste disposal. The heart gets its blood supply from coronary arteries. These arteries can get clogged by cholesterol-filled plaques of atherosclerosis, causing a permanent obstruction.
Such a permanent obstruction can cause symptoms such as pain (the condition called angina), or a weaker heartbeat when the heart is forced to work harder than normal. The heart works harder during exercise and during times when people get angry or their blood pressure is high (for example, because they are not taking their blood pressure medication).
Medicines can help reduce the work of the heart. An aggressively healthy lifestyle, over many months, can shrink the size of the obstructing plaques. However, sometimes a permanent obstruction from a plaque needs to be eliminated promptly. The two main treatments are angioplasty plus stenting, or Coronary Artery Bypass Graft (CABG) surgery.
Angioplasty plus stenting: A small balloon wrapped in a collapsed stent is inserted into a blood vessel in the groin or arm and maneuvered into the heart. When the balloon is inflated, it flattens the cholesterol-filled plaque that was restricting blood flow. The balloon is deflated and removed. The stent remains behind to prop open the artery.
CABG: (Coronary Artery Bypass Graft) During open-heart surgery, an artery or vein taken from elsewhere in the body is stitched in place to reroute blood around the blocked artery.
The choice between angioplasty and bypass depends on a number of factors. I spoke to my colleague, interventional cardiologist Dr. Donald E. Cutlip, for more details.
When all three of the heart’s coronary arteries are narrowed or blocked, bypass is the better choice. (The doctor might make an exception if a patient is too frail to undergo surgery.) Also, for patients with diabetes, CABG (Coronary Artery Bypass Graft) is generally superior to angioplasty.
When fewer than three coronary arteries are affected, the choice depends on which arteries are involved. The left anterior descending artery (LAD) feeds blood to more of the heart muscle than the other two coronary arteries. When the LAD is narrowed or blocked, bypass surgery usually is best.
With colleagues at Orca Health, we have recently published inexpensive iBooks for the Apple iPad and iPhone on angioplasty and stent, and on CABG (Coronary Artery Bypass Graft) surgery. They show you — with spectacular videos — what happens during these procedures: more