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Reducing the Trauma From Heart Surgery

Medicine: Doctors are performing bypasses through 'keyhole' incisions that cause less damage, speed recovery.

May 26, 1997|THOMAS H. MAUGH II | TIMES MEDICAL WRITER

More than 400,000 Americans have a bypass every year to open blocked arteries leading to their hearts. The surgery is almost routine, the success rate is high and mortality is remarkably low, considering that surgeons are manipulating the pump that keeps us alive.

But the psychic toll--paid in pain and lost time--is also high. Bypass patients spend six to 10 days in the hospital and another two to three months recuperating at home before they return to a normal life.

The painful aftermath usually results not from the heart itself--even a couple of days after open-heart surgery, it's pretty much back to normal, ready for business. Rather, the lengthy debilitation involves recovery from the massive trauma to the chest bone.

Cardiac surgeons saw the breastbone in half, pry it apart, and stretch muscles in the chest and back--all to lay the heart bare for their surgical instruments. The procedure is called a sternotomy.

"It's pretty painful," says Dr. Alfredo Trento, chairman of Cardiothoracic Surgery at Cedars-Sinai Medical Center. The breastbone can ache for weeks, and deep breaths may be agonizing.

But perhaps not much longer. Within the last two years, cardiac surgeons have developed techniques to perform so-called keyhole surgery on the heart through tiny incisions that cause less damage to the breastbone, or none at all.

Patients who have undergone the new techniques are often home from the hospital in a couple of days and back to work in a week or two.

The surgery could ultimately prove valuable for 90% of the 70,000 patients who undergo heart valve surgery in the United States each year, more than half of those who undergo a bypass, and perhaps for an equally large fraction of the 400,000 who undergo angioplasty.

Minimally invasive heart surgery "has taken off like wildfire," said Dr. Steven Colvin of the New York University Medical Center, a pioneer who has performed the procedure more times than anyone else in the country. "People come from all over the East Coast, from the Midwest, to get it done. . . . It's growing faster than I ever anticipated."

The minimally invasive techniques "do as good a job as the standard approach," Trento said, "but they are much less traumatic. The advantage of a small incision is that the pain is less. By the time you go home [from the hospital], you're pretty much ready to go back to work."

"This is the wave of the future," added Dr. Namir Katkhouda, chief of minimally invasive surgery at University USC Hospital.

Others caution, however, that the long-term stability of repairs made with the new techniques has not been demonstrated, that the surgery takes longer to perform and is more expensive than conventional open-heart surgery, that it has so far been performed only on a few hundred patients around the world and that its safety has not been proved.

Such surgery "continues to be investigational," said Dr. Robin Cohen of University USC Hospital. "We can only hope that it turns out to be as good as we predict."

Proponents of the techniques note that the same arguments accompanied the introduction of keyhole surgery for gall bladder removal seven years ago. "At first, everybody was skeptical," said Dr. Aidan A. Raney Jr. of Hoag Hospital. "But now it is the standard of care."

One Patient's Testimony

One patient who swears by keyhole surgery is Bill Selditz, a 58-year-old real estate appraiser and part-time drummer from Mar Vista. Selditz had already had two angioplasties for a partially blocked artery when, while walking up the steps from the polls in November, "my body suddenly felt like Gumby, like it was made of rubber."

His left anterior descending artery, the so-called "widow-maker" artery, was blocked too close to the heart for another angioplasty, so Selditz became one of the first patients at Cedars to undergo the new surgery through a technique called port access. The surgery was performed by Trento the Monday before Christmas.

When Selditz regained consciousness that afternoon, his first recollection was that "I hoped I wasn't waking up and the operation wasn't over, because there was no pain whatsoever. The only discomfort was the ventilator down my throat. My only pain medicine [the next day] was Tylenol. I sat up in a chair for 2 1/2 hours and walked around the hospital for 35 minutes."

On the way home from the hospital the next Saturday, Selditz--who lives alone--stopped by the drugstore and the grocery store for supplies. "The next day I went out for a haircut," he said. He was working at home the following week. "I was damn lucky I was there at the right time"--when Trento started performing the surgery.

A Casualty of Modern Lifestyle

The heart is a major casualty of the high-fat diets and low-exercise lifestyles of modern times. Cholesterol in the blood condenses on the interior of the arteries supplying the heart, squeezing off the blood supply and draining the heart of energy.

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