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.
IN JUNE 1997 SARAH CLAIR BURKE OF MONAHANS got just about the worst results a patient can get from a heart-stress test. Moments after stepping off the treadmill at Medical Center Hospital in Odessa, she began suffering severe chest pains. Burke thought it was indigestion, but her doctor was worried about angina. He gave her nitroglycerin and ordered more tests. During a thallium scan—an imaging technique that allows doctors to study blood flow through the heart muscle—Burke suffered further symptoms of a diseased heart, including intense aching in her arm muscles and jaw. Finally, doctors conducted an angiogram and found six severely obstructed blood vessels in her heart.
At 64, Burke was no stranger to the knife, having undergone a C-section, throat surgery, and a hysterectomy. But the prospect of open-heart surgery—the only sure solution for this degree of coronary-artery disease—concerned her. Coronary artery bypass graft (CABG, or “cabbage”) is one of surgery’s most successful and venerated procedures but also one of the most barbaric. Burke knew that firsthand from having observed what the operation had done to her husband, William, back in 1989. “He had a lot of pain afterward,” she recalls, “and he was depressed.”
Her cardiac surgeon, Sudhir Srivastava of Cardiac Surgical Associates in Odessa, proposed an alternative, one that had not existed when her husband had undergone open-heart surgery: minimally invasive, port-access coronary artery bypass surgery. The procedure, which had been sanctioned by the Food and Drug Administration for less than a year, promised a patient like Burke the needed revascularization of her heart with considerably less of the invasiveness, trauma, and post-operative pain associated with CABG. Instead of splaying the patient’s chest out with a foot-long sternotomy to perform the necessary vessel grafting, the surgeon operated with customized instruments through a small four-and-a-half-inch port, cut out of one of her ribs on the left side of her torso.
Benign as it sounded, port-access CABG was not without risks. Some of Srivastava’s colleagues at Medical Center Hospital and representatives of the technique’s inventors, Heartport, a biomedical device company in Redwood City, California, were nervous about using it for the quintuple bypass Burke required. The technology (trademarked by Heartport as Port-Access) had never been applied so ambitiously. Could even a skilled surgeon like Srivastava accomplish a successful quintuple bypass through an incision shorter than the length of his hand?
The 49-year-old native of India believed so. He understood the worries but thought that Burke was still a perfect candidate. Despite the number of clogged arteries she would have to have bypassed through grafts, the blood vessels in her legs and stomach were sturdy enough to withstand the complex catheterization required by the procedure. Also, as a diabetic, whose wounds tend to heal slowly, she would benefit from the diminished trauma. Beyond that, Srivastava—who had gone through the training but not yet performed the operation—believed the procedure could handle five-vessel sur-gery. “It’s like with all new techniques,” says the surgeon, echoing the sentiments of an earlier generation of groundbreaking Texas heart surgeons like Michael DeBakey and Denton Cooley. “There always comes a time for a first.”
Burke had long since made the decision. “I had everything to gain and nothing to lose,” she says. “I’d already put it in the Lord’s hands. And I truly felt like it would be a good thing to be involved in a new procedure that might save a lot of other diabetics who have heart problems a lot of pain.”
So on June 26, 1997, Sarah Clair Burke and Sudhir Srivastava quietly entered the annals of medical history as patient and surgeon in the first minimally invasive quintuple bypass performed anywhere. Not that the event carried the aura of a medical epoch. Indeed, one of the most striking things about this revolutionary new surgery is how undramatic it is.
TRADITIONAL CORONARY BYPASS SURGERY has always represented modern surgery at its most muscular and sensational: the cracking of the chest, the spurting blood, and the exposed, beating heart. This high drama comes from the need to connect the patient to a heart-lung machine (cardiopulmonary bypass machine, or CPB), which pumps and breathes for him during the operation. First employed by Philadelphia doctor John Gibbon in 1953, after decades of arduous experimentation, the CPB revolutionized cardiac surgery by allowing heart surgeons to stop the heart and clear the pericardium of blood for a substantial period of time, enabling them to perform complex procedures ranging from valve repair and replacement to CABG and heart transplantation. As momentous as the CPB was for heart surgery, it created its own reign of terror by requiring a full sternotomy, resulting in massive trauma to muscle and bone and a lengthy, painful recovery. Additionally, a CPB, it was discovered, can cause medical problems for patients: Attachment to it can be especially hard on patients with pulmonary insufficiency, kidney disease, or a history of stroke. Even as other forms of surgery became more patient-friendly in the late eighties through video-enhanced endoscopy—the use of tiny, fiber-optic imaging devices that could be inserted into the body through a small incision to provide the surgeon with a full view of an organ—cardiac surgery remained something of a draconian throwback simply because of the surgical mandates of the CPB.
With port-access CABG, a heart-lung machine is still used but with a lot less mess. The patient is attached to the CPB via a series of catheters and cannulas that are painstakingly threaded through veins in the legs and stomach. Once a patient like Burke is safely supported by the CPB, the heart bypass graft is accomplished through the same small port through which the CPB was engineered. The surgeon views his work on a video monitor via a fiber-optic probe that displays the unexposed sides of the heart. To further minimize trauma and pain, the easily acces-sible left mammary artery is the vessel of first choice for the graft; if additional vessel tissue is needed, as in Burke’s surgery, arteries from an arm and a thigh are harvested. The only real drama to be found in the procedure is in its aftermath. When Burke came out of the anesthetic last June, she hurt a lot less than her husband had after traditional CABG. “I felt almost no pain,” she recalls. “It seemed like I was able to walk right away.”
Indeed, Burke was released from the hospital barely three days after quintuple-bypass surgery, less than half the post-op hospital stay of the traditional CABG patient. More important, she was able to get back to some semblance of her ordinary routine within two weeks—again, less than half the recuperation time of the regular bypass operation. “I was walking up to a mile inside a week. My husband felt dizzy and weak after his. I never felt any of that, and I haven’t felt depressed yet.” “The key here,” says a beaming Srivastava, “is that the patients don’t feel disabled after the operation—either physically or psychologically. We’re able to get them home sooner, where recuperation is always better. Sarah was back to her normal life in two weeks, instead of two months. Home food is better than hospital food, you know.”
Less pain, less recuperation time: Minimally invasive heart surgery has become immensely popular in a short period of time. Nearly five thousand port-access CABG procedures have been performed nationwide thus far, and the operation already has a competing approach, minimally invasive direct coronary bypass surgery, or MIDCAB. Here, too, a Texas surgeon is at the vanguard of the movement: William Mack of COR Specialty Associates of North Texas, a cardiothoracic surgery practice based at Medical City Dallas Hospital. Mack says MIDCAB may be superior to port-access CABG because it eliminates the use of the heart-lung machine altogether and demands that the surgeon work on a beating heart. “The two leading causes of morbidity in bypass surgery,” he notes, “are the sternotomy and the CPB. This eliminates both. Over several decades we’ve gotten good enough as surgeons to be able to operate on the beating heart successfully.”
Mack says that some preliminary studies have shown that MIDCAB can reduce heart surgery costs by as much as 40 percent. As for MIDCAB’s inability to handle more than single or double bypasses—“That’s true,” he says, “but a major change in surgery these days is that we can do hybrid operations—a MIDCAB graft on one artery, angioplasty on two others, for example. Heart surgery is getting to where we understand that we don’t have to hit the home run every time. A lot of times, a single or a double is best.”
PUSHING MEDICAL TECHNOLOGY TO extremes is nothing new to Texas medical centers. Since the heart surgery revolution first erupted in the fifties, the state has remained at the epicenter of the action. If doctors like Michael DeBakey and Denton Cooley weren’t inventing new, life-saving technologies, they were applying the innovations of others with conspicuousness and daring. The first heart transplant may have been performed in 1967 by Christiaan Barnard in Capetown, South Africa, but it was Houston that became known as Heart City, largely because of the sheer volume of operations performed by DeBakey at Methodist Hospital and Cooley at St. Luke’s. The first CABG is most commonly credited to Cleveland surgeon René Pavaloro in 1968. But DeBakey and Cooley popularized the procedure and, indeed, mass-marketed it in the sixties. (For the record, Texas history says the first CABG was devised during emergency surgery in 1964 by Houston surgeon H. Edward Garrett. The operation was not officially reported until long after Pava-loro’s feat. DeBakey, for his part, claims to have performed the first one in 1964.)
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