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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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.)
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.