Surgical DIVIDES

The beating heart
How can intelligent, experienced surgeons totally disagree over
which surgical procedure is best for their patients?
A coronary bypass surgery creates a new passage for blood to flow to the heart to bypass a blockage. A graft from an artery or vein is taken from another part of the body and sewn in place to reroute the blood around the clogged artery.
Dr. Paul Seifert, a cardiac surgeon at Waukesha Memorial Hospital and the Wisconsin Heart Hospital, used to get frustrated when he would perform a technically perfect heart bypass surgery, only to see the patient later suffer a stroke.
A stroke is one of several possible complications patients can suffer after a coronary bypass surgery when they are hooked up to a heart-lung machine during the procedure.
In the mid- to late 1990s, heart surgeons began using the “beating heart” technique during heart bypass surgery, as new equipment became available to help steady part of the heart. During beating heart procedures, the patient is not hooked up to a heart-lung machine. Instead, the patient’s heart continues to beat as a cardiac surgeon carefully attaches a bypass graft to the heart.
Today, heart surgeons in the
United States use the beating heart technique for about 20 to 25 percent of bypass surgeries.
However, the emergence of the beating heart technique is stirring a significant debate among heart surgeons in the Milwaukee area.
Some surgeons, such as Seifert, perform the procedure on a much more frequent basis. Seifert, who has performed more than 1,000 beating heart bypass surgeries, uses the procedure for about 90 percent of his bypass patients.
“Everybody is a candidate to have the surgery done that way unless I find a reason not to do it,” he said.
Seifert uses the heart-lung machine only if the patient has a massively enlarged heart or has recently suffered a serious heart attack.
Conversely, many heart surgeons still prefer the traditional technique of using the heart-lung machine. In that procedure, a tube is connected to the heart’s right atrium, and blood flows through that tube into the heart-lung machine. The machine removes carbon dioxide from the blood, replacing it with oxygen, then the treated blood is pumped through another tube into the patient’s aorta. The machine does the work normally done by the heart and lungs, so the heart can stop beating during the operation and be kept still for the surgeon to work on it.
Some surgeons who prefer the traditional bypass surgery with the heart-lung machine say that procedure results in better, more precise bypass grafts. Those grafts will stay open longer than the bypass grafts attached by a surgeon while the heart is beating, they say.
“The operating we do the most often is the operation that has stood the test of time,” said Dr. David Kress, a cardiac surgeon at St. Luke’s Medical Center in Milwaukee, who prefers conducting bypass surgeries with the use of the heart-lung machine. “It’s the procedure that is most likely to give the patient the best results.”
Some hospitals in the Milwaukee area have surgeons who frequently use the beating heart procedure for coronary bypass surgery, including Waukesha Memorial Hospital, Community Memorial Hospital in Menomonee Falls and St. Joseph Regional Medical Center in Milwaukee.
Meanwhile, surgeons at other hospitals, including St. Luke’s, St. Francis Hospital in Milwaukee and St. Mary’s Hospital in Milwaukee, still prefer the traditional bypass surgery technique with the heart-lung machine.
Surgeons on both sides of the debate can point to at least one study to support their point of view.
A study published in January 2004 by the New England Journal of Medicine said bypass grafts attached during a beating heart surgery do not last as long as grafts attached during a traditional surgery with a heart-lung machine.
However, another study published later in 2004 by Circulation: Journal of the American Heart Association, showed that artery grafts attached during beating heart and traditional bypass surgeries were equally effective. Furthermore, a study released in 2003 showed a reduction in death rates, strokes and other surgery complications from bypass surgeries on patients who had the beating heart procedure.
The beating heart procedure must be studied further to better understand its benefits and shortcomings, said Dr. Hossein Almassi, a cardiac surgeon who practices at Froedtert Memorial Lutheran Hospital in Wauwatosa and the Charles J. Zablocki VA Medical Center in Milwaukee.
Almassi does the beating heart procedure for about 70 percent of his bypass patients, and he also teaches the beating heart procedure at the Medical College of Wisconsin in Wauwatosa.
“Some surgeons swear to it,” Almassi said. “Others just stay away from it, and still others are in-between.”
The Zablocki Center is one of 16 VA hospitals in the nation participating in a study of the beating heart procedure. Patients must agree to participate to be included in the study. The local VA is then told either to perform a beating heart bypass procedure or a traditional procedure with a heart-lung machine, and then patients are monitored afterward.
St. Luke’s performs more heart bypass surgeries than any other hospital in the state, but only about 18 percent of the bypass surgeries there are done on a beating heart.
By contrast, more than 90 percent of the bypass surgeries at Waukesha Memorial and Community Memorial hospitals are done on a beating heart.
Those statistics reflect the divergent philosophies about the beating heart surgery held by the surgeons at area hospitals.
Kress was one of the first heart surgeons in Milwaukee to perform the beating heart procedure in the mid- to late 1990s. Now, he only uses the beating heart procedure for the oldest and sickest patients, whose bodies probably could not handle the heart-lung machine. Many surgeons say those patients benefit the most from the beating heart procedure.
“We use (the beating heart procedure) in patients where they have a specific reason to do it that way,” Kress said.
Surgeons such as Kress use the heart-lung machine for most patients because they believe the bypass grafts from those surgeries will stay open longer and are more likely to prevent a future heart attack. The heart sits still during a surgery with the heart-lung machine, so the bypass graft can be sewn in place more precisely, they say. It is harder to be as precise while sewing a graft onto a beating heart, so those grafts will not last as long, Kress said.
“It’s really two different operations,” Kress said. “If I have a patient that is very elderly, they are not looking for a 20-year result. So off-pump (beating heart) surgery makes a lot of sense. But a 40- or 50-year-old person, they want an operation that is going to last the longest. We don’t know if (grafts installed on a beating heart) will last more than five or 10 years.”
Patients with calcified aortas can suffer a stroke if the use of the heart-lung machine breaks off a piece of plaque into the bloodstream, Seifert said.
Surgeons who favor beating heart bypass surgery say a skilled and experienced surgeon can sew a bypass graft on a beating heart just as precisely as sewing a graft to a heart that is stopped and attached to a heart-lung machine. Some devices can be used to steady part of the beating heart during surgery.
“We have not seen patients come back with failed bypass grafts any more than we would normally see them after the conventional procedure,” Seifert said.
“You need to be really experienced in the technique to have good outcomes,” said Dr. Husam H. Balkhy, a cardiac surgeon who practices at St. Joseph Regional Medical Center in Milwaukee, Community Memorial Hospital and at the Wisconsin Heart Hospital in Wauwatosa.
Balkhy has done about 1,200 beating heart procedures.
“In my mind, it is just a matter of learning it and learning to do it well. You’ve got to be doing it every day. You have to be in practice. That’s got to be your modus,” Balkhy said.
About 20 percent of the cardiac surgeons in the nation do 90 percent of the beating heart surgeries, Seifert said.
“It hasn’t been adopted by a majority of surgeons,” Seifert said. “It’s harder. It’s harder because you have a moving target. The vast majority of surgeons in this country do the operation the way they were trained to do it (with a heart-lung machine), and they do the operation very well.”
“Maybe it’s not for every surgeon,” Balkhy said. “That might not be in their comfort zone. But it is appropriate for every patient. We don’t need to put the patient at risk of these types of complications. (The heart-lung machine) is invasive, and it’s not necessary.”
Of course, Kress disagrees. “There’s a reason the national average is only 20 percent. It’s not that the rest of us can’t do it. We can do it, but we don’t always think it’s right,” he said.
Women are more likely than men to suffer complications from traditional bypass surgery than men, but their risk of complications from a beating heart surgery is equal that of men, Balkhy said.
In addition, some heart bypass surgery patients whose procedures are done with the heart-lung machine suffer a mysterious condition that some surgeons call “pump head.” Such patients suffer a slight change in personality and in cognitive function. Surgeons have theories, but they are not certain what causes the condition.
“It’s not so much stopping the heart that is the problem,” Seifert said. “The problem is it’s not normal to run your blood through a machine for an hour or two.”
Work is ongoing to improve the heart-lung machine and reduce the complications suffered by patients, Kress said.
“We are doing intense study to make the heart-lung machine safer,” he said.
The beating heart surgery also can result in complications, including heart attack or shock, Kress said.
Surgeons who favor the beating heart procedure say their patients recover quicker after the surgery and are out of the hospital and back at work sooner.
“There is evidence the recovery
is quicker,” Balkhy said. “Consistently, patients are better in recovery off
the pump.”
But again, local surgeons also disagree on that point.
“I haven’t seen improvements in the length of stay (for beating heart patients) or the reductions in complications that others tout,” said Dr. Frank Downey, a cardiac surgeon who operates at St. Luke’s and at Columbia Hospital.
Downey has been a practicing heart surgeon for 12 years and only uses the beating heart procedure on 2 to 5 percent of the bypass surgeries he performs.
“(Beating heart) is just a different way of doing bypass surgery,” Downey said. “I haven’t been convinced it’s an improvement of what I currently do. I’m an old fart. I do things conservatively. If it isn’t broke, don’t fix it.”
Downey alleges that the push for more beating heart surgeries has been “industry driven,” rather than driven by scientific evidence. He says some companies that manufacture equipment used for beating heart surgeries, including Minneapolis-based Medtronic Inc. and Indianapolis-based Guidant Corp., have invited him to take trips to observe beating heart bypass surgeries done with their equipment, in hopes of convincing more surgeons to do beating heart surgeries with their equipment.
“That’s very common,” Downey said, adding that he has refused to take those trips.
Downey also said he believes some heart surgeons in the Milwaukee area receive stipends from such companies to talk about the virtues of beating heart bypass surgeries, although he declined to name anyone.
“It’s not supposed to be that way,” he said. “It’s supposed to be driven
by science.”
Rich Fischer, a spokesman for Medtronic, said the firm hosts peer training seminars in Milwaukee, Tampa, Atlanta, Detroit, Phoenix and New York for surgeons to attend and learn about the beating heart procedure.
The firm also hosts national symposiums, he said. For Medtronic-hosted events, the company will pay the travel expenses for surgeons who attend and the company will pay an honorarium to a surgeon who makes a presentation, to compensate for their lost wages during the event.
Medtronic is part of AdvaMed (Advanced Medical Technology Association), which has a strict code of ethics limiting what the company can provide to physicians attending such events, Fischer said.
“These are not junkets,” he said. “They are truly learning opportunities for health care professionals.”
Unless more studies show clear benefits of beating heart bypass surgeries, surgeons who prefer the heart-lung machine are not going to change their practices, Almassi said.
“It has gone up and down (in use),” he said. “It has plateaued at about 20 to 25 percent, despite the initial excitement.”
Surgeons who believe in the beating heart procedure and have seen its benefits expect its popularity to grow.
“I think it’s the wave of the future,” Balkhy said.
If any problems occur during a beating heart surgery, surgeons can always switch to the heart-lung machine in the middle of the procedure, he said.
“There’s no question the conventional operation is a good operation,” Seifert said. “It’s been done for 30 years, and it’s saved hundreds of thousands of lives. But you always have to look for ways to do something better.”
April 15, 2005, Small Business Times, Milwaukee, WI