Is the Heart Bypass Necessary?

Cardiologists debate surgery's usefulness for angina victims

In the Disneyland atmosphere, the explosive controversy seemed out of place. But the heated debate about coronary bypass surgery clearly dominated the annual scientific session of the American College of Cardiology, held last month in Anaheim, Calif. TIME Contributor Gilbert Cant attended along with some 7,000 physicians and surgeons. His report:

Dr. Eliot Corday, a past president of the college, was unequivocal. "Bypass surgery," he declared, "is the most important development of the decade in medicine." Not necessarily so, countered a number of cardiologists, notably those affiliated with Veterans Administration hospitals or other federal agencies. Dr. Henry D. Mclntosh, also a college past president, summarized their view in a report published in the journal Circulation: "Except for certain relatively small [groups] of patients, there is no convincing evidence that the procedure prevents or postpones premature death."

The cardiac bypass was first developed as a regular procedure in 1967, when only 37 operations were performed. Since then some 300,000 to 400,000 have been carried out in the U.S. alone, and the 1978 total is expected to top 75,000. The operation involves taking lengths of vein from a patient's leg and stitching them to the aorta and to coronary arteries so that blockages are bypassed. The surgery demands the most skillful surgical teamwork, commonly takes as long as five hours and can cost $12,000 or more.

Some critics of bypass surgery have noted that it is already a $ 1 billion a year industry and that its ballooning costs threaten the future of other health care in the U.S. Joseph Califano, Secretary of Health, Education and Welfare, told a Senate subcommittee that if a preliminary Veterans Administration report proves accurate, "hundreds of millions of dollars could be saved through less frequent use of this expensive surgery."

The controversial VA study was made from 1972 through 1974 and dealt only with a narrowly defined group of patients: those with chronic angina (viselike chest pain) whose conditions had remained stable for six months before their participation in the study. Patients with the most severe forms of coronary-artery disease or other disorders were deliberately excluded. Of the 596 VA patients studied, 310 were treated with medication alone, while 286 had bypass operations. The study's conclusions: medically treated patients had a three-year survival rate of 87%; those who underwent surgery only 88%. That minuscule difference caused distress among many heart disease victims. Those contemplating bypasses agonized over whether to go ahead, while others who had already had the operation wondered if it was worth the pain, trouble and expense.

Attacking the VA study, Corday, a U.C.L.A. cardiologist, charged that "the VA's patients were the most unsuitable group to study because their mortality under medical therapy alone was already less than 1 %." In agreement was Dr. Donald B. Effler, head of cardiovascular surgery at the Cleveland Clinic when his chief associate, Dr. Rene Favaloro, developed the bypass. Said Effler: "I think the VA report has already been shot down, and if not, then it will be before sunset." Favaloro, recalled from his home base in Argentina to deliver one of the session's two principal lectures, made an impassioned, hour-long argument for bypass surgery on properly selected patients. Commented Boston Heart Surgeon Dwight Harken: "Any doubt as to the efficacy and desirability of bypass surgery has now suffered sudden death."

In fact, the VA study did have limitations. It failed to emphasize that among the patients given only medication, 17% eventually had to have bypass surgery to relieve angina. In a similar federal study, fully a third of the patients initially treated only with drugs chose surgery within 2 1/2 years. The VA study's report of a 5.6% mortality rate also came under attack; several centers had already cut that rate to 3% during the study's 1972-74 period, and in some it is now down to less than 1%.

Still, when the shouting finally died down, the VA investigators and their critics were closer to agreement than they admitted. Both emphasized the proper selection of patients. The surgeons conceded that most patients with chronic but stable angina (probably indicating only one blocked coronary artery) do not need a costly bypass. Most also agreed that for victims of the severest disease, characterized by a blockage in the left main coronary artery (a condition that Effler aptly calls "the widow-maker"), surgery is all but mandatory. The same is true for patients with progressive or uncontrollable angina who have two or three diseased coronary arteries. Even patients with these severe conditions who have already suffered heart attacks can, 80% to 90% of the time, be freed of pain by bypass surgery, and usually return to an active, productive life, including sexual activity.

Surgery advocates argue that the benefits to the economy from those who return to work are at least equal to the $ 1 billion costs of surgery. That is, admittedly, a top-of-the-head estimate. But Harvard's Dr. John J. Collins Jr. presented some convincing figures from one group of 100 patients who had had bypass surgery. According to Collins, these patients, who before surgery frequently required hospitalization, spent so much less time in hospitals after bypass operations that the saving over a period of about 4 1/2 years equaled the cost of the surgery.

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