It was only 7 a.m., but the operating room in Cleveland Clinic’s cardiovascular unit was going full tilt. Nurses, technicians and visiting doctors watched as members of a surgical team took their places around the operating table. With confidence born of experience, the surgeons made a vertical incision from the patient’s collarbone to his diaphragm, sawed through his breastbone and then, using a framelike mechanism, spread the rib cage and exposed the pericardium, or heart sac.
As if on cue, Dr. Donald Effler, tall, athletic and at 55 one of the country’s leading heart surgeons, strode into the operating room. Taking his place among his subordinates, he slit open the pericardium and examined the heart. Another surgeon, meanwhile, opened the patient’s thigh and removed a foot-long section of the saphenous vein, one of four major veins that carry blood from the lower limbs to the heart. Effler began rapping out commands like a drill sergeant, initiating the procedure to shut down the patient’s heart and turn its functions over to a heart-lung machine. Then, after stopping the still-beating heart with a split-second electric shock (“Juice!” he demanded), Effler began the operation that would save his patient’s life—inserting pieces of vein cut from the leg to bypass two blocked coronary arteries, the heart muscle’s principal source of blood.
Repertory of Repair. Only four years ago, this and other operations to improve the circulation of blood to overtaxed hearts were either unknown or experimental. Now revascularization, or “replumbing,” has become the most popular item in the thoracic surgeon’s repertory of heart repairs—and with good reason. Most of the 500,000-plus Americans who die each year of heart disease suffer from atherosclerosis, the buildup of hard, fatty deposits that narrow the coronary arteries and cut off the flow of oxygenated blood to the heart muscles. Only revascularization, which is simpler and safer than transplant surgery, offers many patients a chance for survival.
Effler’s team alone has played plumber to more than 5,000 diseased hearts since 1962, and doctors attending last week’s meeting of the American Association for Thoracic Surgery in Atlanta report that revascularization is being performed at an increasing number of hospitals. Still, doctors are reaching only a small fraction of their potential patients. Nearly 250,000 Americans a year, or the majority of newly identified atherosclerosis victims under 65, could benefit from reconstructive heart surgery. But because trained personnel and adequate facilities are in short supply, doctors are performing only 25,000 operations a year, a fact that Effler finds appalling.
“This is an essentially simple operation,” he says. “It’s got to be kept simple because we’ve got to get heart repair to the community-hospital level.”
Though there is still a long way to go. progress to date has been impressive. In 1946. Montreal Surgeon Arthur Vineberg, figuring that the internal mammary artery (see diagram) is dispensable, carefully cut it away from the breastbone, left its upper end in place, and implanted its lower end in the left ventricle, the heart’s primary pumping chamber. A decade later, Dr. Charles P. Bailey, then in Philadelphia, developed a procedure called endarterectomy, in which he opened a blocked coronary artery and reamed out a plug of accumulated cholesterol with a device resembling a crochet hook.
X-Ray Movies. No one, however, did more to advance the cause of cardiac revascularization than Dr. F. Mason Sones Jr., a Cleveland cardiologist who in 1958 developed a method of mapping the cardiovascular system. Known by the jawbreaking name of cine coronary angiography, Sones’ technique involved inserting a catheter, or thin piece of tubing, into an arm artery, guiding it up through the aorta and then squirting a radiopaque dye through it directly into the coronary arteries. The dye, which showed up clearly on motion picture X rays, made it possible for physicians to see with 90% accuracy exactly where the coronary arteries were blocked. The Sones method also enabled cardiologists to evaluate the results of their operations and proved beyond any doubt that the Vineberg implant measurably improved circulation of blood to the heart muscles.
Armed with this knowledge, Effler began performing Vineberg implants on patients suffering from angina pectoris, the crippling pain that signals insufficient blood supply to heart muscles. But other surgeons, still skeptical, concentrated on alternative approaches. Dr. Philip Sawyer of New York’s Downstate Medical Center in Brooklyn developed a method of using pressurized carbon dioxide gas to separate the inner and outer walls of an artery so that the fat adhering to the arterial lining could be more easily removed. Others experimented with widening clogged arteries by inserting gussets made from pieces of the patient’s saphenous vein.
All the operations worked moderately well. But what revolutionized revascularization was a procedure developed at the Cleveland Clinic by Dr. René Favaloro, now 48, an Argentine-born surgeon who joined Effler in 1962 to study coronary-artery disease. In an operation first performed four years ago next week, he removed a section of his patient’s saphenous vein, attached one end to the blocked right coronary artery at a point below the obstruction, stitched the other to a spot on the aorta above the blockage. The procedure allowed blood to bypass the blockage and greatly improved the heart’s blood supply.
Fast Operator. Since then, the operation has been refined and perfected. The Cleveland Clinic alone has done nearly 2,000 bypass grafts; institutions like Stanford University Hospital and Massachusetts General Hospital have performed hundreds. Few surgeons are more adept at the operation than Effler, whose team does at least half a dozen a day.
Once the heart has been stopped, Effler calls for the saphenous vein, measures it and cuts off the required length. Then he sews it into place, first below and then above the obstruction. With the first graft in place, Effler repeats the procedure on the right coronary artery and checks to make sure that there is no leakage. This done, he disconnects the patient from the heart-lung machine, restarts the heart with a second electric shock and slips out of the operating room for a breather while an assistant cuts away the mammary artery. A few minutes later, Effler returns, implants that artery in the left ventricular wall and steps back so that his assistants can take over and close the wound.
A fast operator, Effler performs most bypass grafts in about three hours, half the time the procedure once took. “Let me tell you,” he warns a group of residents, “that if I ever find any one of you taking six hours for an uncomplicated case, you’ll be looking for another appointment the same afternoon.” His sense of urgency is understandable. The longer the patient stays on the heart-lung machine, the greater the damage to his blood cells and the higher the risk of postoperative problems.
Gas and Pass. Effler and Favaloro believe that bypass grafts, particularly when combined with mammary implants, are the ideal solution to most coronary conditions. Dr. W. Dudley Johnson of Milwaukee, a hard-driving perfectionist who claims credit for the first double and triple bypass grafts, tends to agree, though he differs slightly in his approach to arterial problems. He questions whether angiography tells a surgeon all that he needs to know and feels that some conditions must be observed more thoroughly to be properly evaluated. As a result, Johnson operates on many patients whom the Cleveland crew would reject as unfit. But Stanford’s Dr. Norman Shumway Jr., inventor of the heart-transplant technique, has reservations about his colleagues’ methods. He believes that mammary implants, which may take months to improve ventricular circulation, are impractical. Instead he combines bypass grafts with the gas endarterectomies in what his operating team calls a “gas and pass” procedure.
All agree that revascularization, like all heart surgery, is risky. Though Cleveland Clinic lost only four of the 255 patients (1.6%) in replumbing procedures performed in February and March of this year, overall in-hospital mortality in such cases is 5%.
Alive and Well. For most coronary patients such hazard is acceptable. “Risks are statistics,” explains a doctor in Rachel Mackenzie’s newly published Risk (Viking; $3.95), an account of her experience with heart surgery. “So far as you’re concerned, they’re 100% or they’re zero.” The doctor is right, and for those who survive heart surgery, the prognosis is promising. Of Johnson’s revascularization patients, 77% have survived at least two years after their operations; some of Effler’s earliest patients have lived three years with their new plumbing. Most bypass patients are not only alive, but well. A Massachusetts lawyer who underwent an emergency bypass graft a year ago has resumed his law practice, and Jack Chronin of New York, who had his cardiac plumbing redone last October, has recovered even more remarkably. Determined to keep himself and his heart healthy, he has taken up jogging.
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