State of the Heart
Following in the footsteps of legends like Michael DeBakey and Denton Cooley, Texas doctors are perfecting “minimally invasive” alternatives to coronary bypass surgery. And the beat goes on- with a lot less pain.
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It’s easy to argue that this by now almost mythological connection between Texas and the heart is merely a matter of happenstance, that a couple of brilliant and energetic surgeons just happened to be cutting at Houston hospitals precisely when open-heart techniques were ready to go public. But DeBakey and Cooley were not practicing in Houston by accident. Their exploits—and Houston’s attendant fame—grew out of the big budget and bigger ambitions of Houston’s Texas Medical Center, the gargantuan maze of hospitals, research centers, and medical schools that remains Houston’s most bodacious monument to its own bodacity. Founded in the thirties, the Medical Center became the quintessential post-war Texas institution: a newer, bigger, bolder version of what everyone else had. Given the estimable donations of the city’s oil-rich, not to mention the state contributions aimed at expanding Texas’ university system and federal tax dollars for bio-medical research, the facility had plenty of money to offer bright young doctors like DeBakey and Cooley. But more than that, it had a kind of entrepreneurial spirit lost on the nation’s older, more staid medical institutions. Precocious, daring young scientists sensed they could flex their muscles in Houston and not have to wait for someone to die to do it.
And few areas of medical pursuit required more daring than heart surgery. Though medicine had been at the business of removing, cutting, and splicing diseased body tissue for centuries, it was always a crude art and an even cruder science. The first operation with anesthesia wasn’t performed until 1846; before that, surgical patients were literally knocked out, held down, or rendered numb by whiskey. Antisepsis wasn’t employed until 1865, when physician Joseph Lister applied carbolic acid to keep wounds clean; sterilization of surgical instruments wasn’t introduced until 1889. True progress didn’t arrive until World War II and the years immediately thereafter, when surgical innovations gushed forth: Blood transfusions became routine, penicillin was discovered, anesthesiology grew much more sophisticated. As antibiotics and anesthesias became more varied and plentiful, surgery entered what is known as its golden age.
If there was a watershed for open-heart surgery, it came in 1958, when heart surgeon Denis Melrose, utilizing a vastly improved heart-lung apparatus, performed open-heart valve repair on a patient on national television. Not only did the improved heart-lung machine keep the patient alive and stable while Melrose did the intricate repair to the heart, but a national audience also sat spellbound and watched the entire operation. Almost overnight the public perception of surgeons shifted 180 degrees. Once viewed as medical brutes, surgeons quickly ascended to the pantheon of folk heroes; they were miracle workers. The body’s most sacred organ had finally been cut on, and the result had been much more good than bad. It was the dawning of the era of Big Science, and heart surgery, along with computers and the nascent space program, would soon change the way we looked at the world.
But as surgeons like DeBakey and Cooley became celebrities, public expectations of their abilities inflated, which in turn prodded them to push too hard. Nowhere was this tendency more pronounced than in heart transplantation. Despite the fact that Barnard’s first transplant recipient died fifteen days after surgery, DeBakey and Cooley jumped headfirst into the transplant business. Between 1968 and 1969 alone, Cooley performed eight transplants and DeBakey a dozen, with results as depressing as Barnard’s.
As the body count for transplant patients continued to mount, heart surgeons were faced with their first serious reckoning since the open-heart revolution began in the late fifties: Nowhere in medical practice was the Hippocratic advisory, “First, do no harm,” more at risk of violation than in the modern cardiac operating room. DeBakey, the de facto leader of the breed, took a hiatus from transplantation and focused his attention on cardiac surgery’s latest miracle: coronary artery bypass surgery.
Not only was CABG much safer than transplantation but it also finally addressed the pervasive problem of clogged arteries and their painful consequence—angina. Until CABG came along, much of the progress in cardiac surgery had focused on congenital heart malformations and weak or leaky blood vessels. The problem of clogged arteries—the product of steak-eating, whiskey-drinking, chain-smoking post-war affluence—had not been taken on. But as the cases of painful and disabling angina, and its fatal result, the heart attack, became epidemic, the cabbage became cardiology’s focus.
Not all of the attention was positive. From the outset, there were physicians who thought CABG too brutishly invasive, particularly considering that angina already had well-established treatments, notably, nitroglycerin. But nitroglycerin could only relieve an attack of angina. Its many sufferers wanted a cure that would eliminate its onset altogether. So it came as no surprise that, even without the benefit of in-depth studies of the procedure’s effectiveness and hazards, CABG caught on. By 1972 surgeons were performing 20,000 CABGs a year. Once many of the medical doubts about CABG were assuaged, the procedure’s critics turned their skepticism to the hastiness with which medical centers and clinics were penciling the procedure into surgical menus. Indications were that CABG was a reasonably safe procedure, but only in the hands of surgeons who had performed a large number of open-heart operations. Skeptics wondered if economic considerations weren’t outweighing medical prudence: CABG was a big-ticket procedure, and considering the pervasiveness of angina, hospitals stood to turn their surgical services into profit centers. Indeed, by 1977, when the number of CABGs performed annually nationwide had rocketed to 70,000 at an estimated cost of $1 billion, many grumbled about the coronary bypass industry that was burgeoning across the nation. The grumbling got louder as the number reached 136,000 in 1980 and more than a quarter of a million in 1990.
DeBakey, for one, thinks the criticism was unwarranted. “A lot of it,” he says, “was based on a story on 60 Minutes that said there were too many unnecessary heart surgeries. I know that we never did surgeries that weren’t serious cases of triple-coronary heart disease.” And he stands by the procedure, for all its brutality: “People forget that the main reason CABG became so popular so quickly was that it worked.” CABG has certainly established an enviable track record. While still relatively pricey—between $40,000 and $50,000—its morbidity and mortality rates are minimal. In nine out of ten bypass operations, the grafts last at least ten years, which translates into a lot of lives lengthened and a lot of pain and disablement prevented. Mortality from the procedure is about one percent.
Today, despite its critics, heart-bypass surgery has never been more popular. More than 400,000 CABG and valve procedures were performed in 1997; the industry has grown into an estimated $20-billion-a-year business. Bypass surgery has become an unfortunate rite of passage for American men middle aged and older.
THE LATEST EVOLUTION IN CARDIAC surgery has a distinctly nineties aura to it; indeed, minimally invasive surgery is less a product of Big Science than it is of the expanding biotech industry. And while firmly rooted in sound biomedicine, the techniques were fomented more by the marketplace—consumer demand and potential cost savings—than anything else. Despite CABG’s success rate, prospective patients wanted an alternative to its trauma and post-operative pain; hospitals wanted what prospective patients wanted. The managed-care establishment wanted whatever would cut back on a patient’s hospital stay. (For a time, angioplasty—the technique in which a balloon is threaded through the clogged artery—appeared to be the answer to CABG’s severity. But despite its popularity, and there are now more angioplasties performed each year than CABGs, its long-term results have been uneven: A quarter to a half of all vessels cleared by angioplasty become reclogged within six months.)
Srivastava, Mack, and other practitioners of the new bypass techniques labor far from the celebrity spotlight that DeBakey and Cooley operated under. Rather, they are quiet and unassuming masters of ever-changing technology as well as astute marketers of new biotechnology. Mack, in fact, recently added another surgical first to his résumé, becoming the first surgeon to use minimally invasive technology to perform transmyocardial laser revascularization, an already established procedure for patients with advanced coronary disease that eliminates the vessel-grafting process altogether. Aiming lasers through a port, the surgeon burns a series of tiny wounds into the muscle of the oxygen-starved heart; the wounds then promote the growth of new blood vessels, reviving the organ.
The question now is whether all this market-driven innovation will prove to be as good tomorrow as it looks today. Even enthusiasts like Srivastava and Mack are cautious in their predictions. While being easier on the patient, port-access CABG has thus far proved to be actually more time-consuming and expensive than traditional CABG surgery, Srivastava says. And neither procedure is for everyone. Various studies suggest that anywhere from 30 percent to 50 percent of heart patients can be operated on with port-access CABG; the two-artery limitation of MIDCAB makes it an option for only a small percentage of surgery candidates.
And there are questions about whether the more benign procedures provide the patient with as sturdy a set of new pipes as conventional CABG. A review by the Blue Cross and Blue Shield Association’s Technology Center concluded that “the evidence does not permit conclusions on the health outcome effects of minimally invasive CABG, or whether these compare favorably to conventional CABG or angioplasty.” The report went on to point out that “numerous reports of acute or subacute vessel stenosis [abnormal narrowing of the vessel] following minimally invasive techniques raise the question of whether short-term stenosis occurs with greater frequency than with other approaches.” A study done at St. Francis Hospital in New York was more positive, finding that port-access CABG techniques “produce outcomes that are comparable to or better than those reported for conventional open-chest cases.”
Problems like stenosis are kinks that will likely be worked out once surgeons pass through the learning curve of the new technology, says Dr. Rafael Espada, the chairman of surgery at Houston’s Baylor College of Medicine, which is in the midst of doing a study comparing port-access CABG with traditional CABG. “It was that way with laparoscopy in the beginning too,” he says. “The real question is, Once surgeons do get the technique down, will it really be any better than conventional surgery in the long run?”
The Baylor survey will seek an answer to that question by comparing minimally invasive surgery patients with conventional CABG patients in three areas: pain, morbidity and mortality, and cost. “You would expect minimally invasive techniques to come out superior in at least the first two categories,” says Espada, “but conventional bypass sur-gery already has an excellent morbidity-mortality record. You have to balance that against those days the patient takes off his hospital stay, and how much sooner he gets back to being productive. In the long run, that could add up to savings that are hard to calculate.”
Sarah Clair Burke, for her part, would have to agree. She now walks three to four miles a day, and although she did have to have a sixth heart vessel cleared by angioplasty, she says she hasn’t suffered a whit of serious discomfort from her surgery nearly a year ago.
“Of all the surgery I’ve had, this was the least troublesome. I’d do it again,” she says, which is saying quite a lot when you’re talking about quintuple-bypass surgery.
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