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Clinton To Undergo Heart Bypass Surgery

Cardiovascular Health

Irving Kron, M.D.
Cardiovascular Surgeon, University of Virginia Health Systems
Friday, September 3, 2004; 3:00 PM

Former President Bill Clinton is scheduled to have bypass surgery at a New York hospital after suffering mild chest pains and shortness of breath. He has been admitted into New York Presbyterian Hospital-Columbia in Manhattan today.

Irving Kron, M.D., chair at the Department of Surgery at University of Virginia Health Systems, was online Friday, Sept. 3 at 3 p.m. ET to discuss the former president's heart condition and surgery.


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Kron is a cardiovascular surgeon and a representative of the American Heart Association.

A transcript follows.

Editor's Note: Washingtonpost.com moderators retain editorial control over Live Online discussions and choose the most relevant questions for guests and hosts; guests and hosts can decline to answer questions.

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Irving Kron, M.D.: Mr. Clinton apparently has had chest pains and he has a condition that would require coronary bypass surgery. He sounds like he is stable and there is every reason to believe that everything should work out. If you have any questions about heart risk and bypass surgery, I'm ready to answer your questions.

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Atlanta, Ga.: Just want to know how risky this is for the President. Is he going to get through okay?

Irving Kron, M.D.: In general, the risk of this operation in an otherwise healthy man should be less than two percent. My expectation is that he should do well. This is a very common operation. As a matter of fact, I just performed one this morning. Most people do extremely well and leave the hospital within five days of the operation and there is every expectation that he should be able to live a normal life. This is one of the most commonly done operation in the United States. The frequency has gone down since the use of angioplasty -- a procedure done by cardiologists in the catheterization laboratory and does not require an incision.

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Cleveland, Ohio: Any knowledge of which coronary arteries are blocked and
by how much?

Irving Kron, M.D.: No, I don't have that level of detail.

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Anonymous: What are the causes for the type of condition? Is diet a contributing causes? I hate to mention this, but I am certain maybe are concerned that all those cheeseburgers weren't too healthy.

Irving Kron, M.D.: This condition is commonly known as hardening of the arteries. The diet is a contributing cause but there's also a genetic predisposition. Diets are particularly important in people who have a genetic disposition. Other secondary causes, which I'm not aware that Mr. Clinton has, may include diabetes and high blood pressure.

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Portland, Ore.: Although most of your Q/A will focus on President Clinton's specific problem and operation, can you please lay out both the targets for good heart health for men his age, as well as danger signs that might signal a weakening heart? Thnx!

Irving Kron, M.D.: Very good question. Basically, routine physicals, good diet and no smoking is critical for men his age. But the blockages he has does not mean a weakening heart. Someone has a weak heart if there is damage from blockages. We have no data that that has occurred. The key point is that an individual should not ignore chest pains. Clearly Mr. Clinton was exactly right to go in and seek medical help when he started having chest pain.

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Washington, D.C.: How could someone, such as a president, whose health has been scrutinized so closely for years, have a heart ailment such as this go unnoticed previously? A quadruple-bypass?

Irving Kron, M.D.: Also a very good question. The type of tests required to diagnose these conditions tend to be invasive and carry a risk with the test itself. So therefore, we don't do those tests unless a person has those symptoms or other warning signs. There are some screening tests that are available such as stress tests and we recommend those for people who either have symptoms or family history.

The symptoms include chest pain (particulary with exertion), shortness of breath with exertion and heart racing.

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Toronto, Ontario, CANADA: Dear Dr Kron,

Why did the American healthcare system fail to accurately diagnose Mr.Clinton's condition well in advance, i.e., at a stage when things would have been prevented before coming to this bypass surgery. Is it a case of deliberate negligence or plain indifference toward the health of a former U.S. President? It speaks volumes for the American healthcare!; An ordinary fellow in the street stands no chance, for sure.

And then, is there no alternative to quadruple or whatever bypass operation at this stage? And how long does it take for complete recovery?

Irving Kron, M.D.: Preventing someone from developing significant blockages is still not completely possible. You can put things off but in the absence of symptoms, you cannot make these things go away. The key is not necessarily prevent them from occuring but rather to treat them before they cause damage to the heart. Our technology throughout the world does not yet allow us to accurately diagnose heart disease at a very early age nor prevent it completely.

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Gearhart, Ore.: Can yo-yo dieting contribute to the stress that one can place on the heart? To an exstream, it's known that it can.
Bill Clinton never appeared to look way to heavy or way to thin at different times of his presidency and after. However, I had heard alot about him trying new diets. Along with his love for junk food, could his dieting to loose wieght on and off have hurt him? Is any diet that is not well balanced a risk to your heart?

Irving Kron, M.D.: There is a role of diet and heart disease. There is no evidence that different types of diets increases your risk of heart disease. Every situation is individual and we don't know for sure what caused this to occur for Mr. Clinton.

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Champaign, Ill.: With all the advances in early diagnosis, why most bypass are done on an emergency basis? Why the blockage is so hard to detect, say years or months ahead of the trouble?

Irving Kron, M.D.: Most bypass surgeries are not done on emergency basis. However many are done urgently -- in other words once an individual has symptoms, then the extent of blockages are described by testing. If they are severe, then it is hard to just treat them electively.

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Washington, D.C.: What is the life expectancy of a patient undergoing quadruple bypass surgery?

Irving Kron, M.D.: If it goes well and the bypasses are successful, he should have a normal life expectancy.

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Bowie, Md.: Does having a coronary bypass happen before mean President Clinton had a heart attack? At first, it was reported that he had a heart attack. Then, there was an update to "chest pains." I was wondering if this change to "chest pains" was some sort of spin so as not to alarm the public.

Irving Kron, M.D.: Having a coronary bypass does not mean that he had a heart attack. A heart attack occurs if a blockage is so severe that causes the portion of the heart beyond the blockage to die. But we have no idea if Mr. Clinton had any damage to his heart. The purpose of a bypass is to prevent damage or further damage to the heart.

Chest pain does not always mean heart attack. There is a term called angina, which means blockages causing chest pain without muscle damage. Anginas are a warning system before a heart attack occurs.

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Brooklyn, N.Y.: I recall reading recently that bypass surgery is much less necessary/effective than previously thought. Is that true? In light of that, why do you think Clinton is having it?

Irving Kron, M.D.: Bypass surgery is very effective therapy. It goes around blockages and reroutes blood. However not everyone needs one. So some patients with blockages can be treated with medications. Others can be treated with angioplasty; those with the most severe blockages need bypass surgery. That is why Mr. Clinton is having it.

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Hershey, Pa.: In President Clinton's case, are the vessels which are believed to be blocked or narrowed so situated that the surgeon will be able to use less invasive techniques where, e.g., the heart may not have to be stopped, etc.

Irving Kron, M.D.: Coronary bypass surgery is the use of either the patient's own arteries or veins to bypass a blockage. Traditionally, it has been done with a heart lung machine so that the heart can be stopped for the most accurate sewing. However some patients can have off pump surgery, that is no bypass machine is used but rather the heart continues to beat while the bypasses are being sewed. These techniques must be individualized to the patient and the patient's condition -- and both techniques have their advantages and disadvantages.

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Boston, Mass.: They say earlier tests at another hospital showed no problem. Do we know if catheterization is usually attempted prior to the decision to do bypass?

Irving Kron, M.D.: He definitely had a catheterization done. You cannot have surgery unless the patient has catheterization. Catheterization provides a roadmap for what will be needed.

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Washington, D.C.: I read reports that Pres. Clinton did not have a heart attack, but that he felt chest pains and shortness of breath. What clinically must happen to be deemed a "heart attack?"

Irving Kron, M.D.: A heart attack is defined as damage to heart muscle beyond the blockage. The amount of muscle that is damaged defines wheter the heart attack is big or small. Again, chest pain usually does not mean a heart attack. If you have chest pain, it can be either a heart attack or a warning sign of a future heart attack, either way it requires medical attention.

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Washington, D.C.: In many cases angioplasty is sufficient to solve the problem. How is a decision made to go for a full bypass surgery?

Irving Kron, M.D.: Angioplasty is very effective therapy for the majority of patients with blockages. Surgery is used if the blockages are very severe or an individual where angioplasty has not been successful.

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Chicago, Ill.: I believe President Clinton used to eat McDonalds hambugers regularly. Please clarify how a heavy red meat fatty diet is harmful. What will his post op and future recommended diet consist of?

Irving Kron, M.D.: Heart healthy diets are usually defined as lowfat. There are so called high protein diets that have been popular recently and they are still being evaluated for heart safety.

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Escanaba, Mich.: My thoughts and prayers are with Mr. Clinton. As you said, he was wise to seek care.

I, myself, am a middle-aged man, who has had heart disease run through my family.
I admit I have a bad diet as well (though I'm trying to change that).

But my question is, I don't want to go into an E.R. room unnecessarily. So, how does one differentiate between simple heartburn and the symptoms of a heart attack?

Thank you.

Irving Kron, M.D.: This is a difficult question. Something that feels like heartburn can also be a symptom of heart disease. In general, if one has symptoms with exertion, that needs to be seen by a physician. If the symptoms are associated with a fast heartbeat or sweating, that should be seen by a physician. If the symptoms persist, you should be seen by a physician.

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Washington, D.C.: I was surprised you did not mention physical activity -- in addition to not smoking and good diet -- as critical to heart health. What is your view?

Irving Kron, M.D.: Yes physical activity is absolutely critical to heart health. However someone who has not been physically active should work their way into a measured physical activity program. Sudden physical activity for someone who is not used to it is not good.

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Washington, D.C.: Given what we've learned about President Clinton's health history--the media has provided details about his cholesterol, blood pressure and general health--what is the chance that bypass surgery will have a significant long-term effect on his health? Could there be complications? Could his quality of life be effected by surgery?

Irving Kron, M.D.: We don't have the details of Mr. Clinton's health history, nor should we. In general bypass surgery is quite successful. His quality of life should be excellent.

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Falls Church, Va.: Why did Clinton not go to the Cleveland Clinic for his surgery?

Irving Kron, M.D.: There are many excellent places to undergo bypass surgery. Columbia University happens to be one of them as is the Cleveland Clinic. The technology for excellent results is now widespread throughout the nation. The critical issue is the experience of the surgeon and the center where the surgeon practices. Patients should ask those questions when surgery is being contemplated.

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Genetic predisposition: I read in President Clinton's book that his father died of heart disease, as well as some of his other relatives. He wrote about wanting to live a long time but acknowledge that genetics could weigh in on that

Irving Kron, M.D.: You are quite right. There is a genetic predisposition for heart disease. However bypass surgery and afterwards, excellent diet and appropriate treatment should allow for a normal life.

If an individual has a significant family history of heart disease you can take measures to reduce your risks. What you can do is get regular medical attention, heart healthy diet, keep your weight down, plenty of physical activity and certainly let your physician know your family heart history. Those are a few things that you can do. Often your physician will prescribe medication if your cholestorol is high and aspirin to reduce the risk of heart disease occuring.

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Staten Island, N.Y.: What about the risk of cognitive problems and memory problems after bypass surgery? Is it a big risk? Do you think Clinton will lose some of his sharpness because of the surgery?

Irving Kron, M.D.: I've been asked this question before. It turns out that cognitive problems and memory problems are infrequent after bypass surgery in younger patients. They are an issue in elderly people who have surgery. I have personally operated on physicians and prominent business people who are easily able to do their job well after surgery.

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Denver, Colo.: I understand that a new MRI scan can detect coronary blockages? How accurate or useful are they in comparison with catheterization?

Irving Kron, M.D.: There is new technology that can detect coronary blockages. They presently are not as accurate as catheterization. However the technology keeps getting better. I expect within the next few years, these technologies will replace catheterization for the diagnosis of coronary artery disease.

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Arlington, Va.: Could work-related stress have been a contributing factor in President Clinton's case?

Irving Kron, M.D.: It's a very difficult question. We don't know the role of stress in developing coronary blockages. It has not been well studied.

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Washington, D.C.: What's usually the life span of a bypass procedure before a second bypass is repeated?
I hear in countries like Australia surgeons are doing laser surgery instead of open heart surgery. Can you please explain?

Irving Kron, M.D.: The life span of a bypass procedure relates to what is used to do the bypasses. Arterial bypasses, that is where the arteries from the chest wall are used, may last forever. Vein bypasses, which are taken by the leg, lasts anywhere from ten to 20 years. Therefore most surgeries these days prefer arterial bypasses for the major vessels. Laser surgery presently has a limited role for bypasses. Laser does not treat coronary blockages, rather it attempts to punch holes in the heart to theoretically bring new blood supply to the heart. There are very few situations where it is used by itself for people with heart disease. We know that laser surgery does not bring more blood supply to the heart. Most common and effective surgery is coronary bypass surgery (that includes open heart and off-pump surgery).

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Irving Kron, M.D.: Thank you for your interest. My prayers are with Mr. Clinton. The American Heart Association web site is a fantastic resource for information on heart disease.

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