And the Beat Goes On

Five minutes after you meet Joel (Barlow) Davis, it feels as if you've known him for years. As open and affable as a handshake, Davis, a retired country-music bass player and singer, wasn't trying to fool anyone the night before he underwent a quintuple heart bypass at Emory Crawford Long Hospital in Atlanta in March. "I'm calm, but I'm scared," he said. "I really am." To relax, Davis, 68, harmonized with his companion Peggy Stone on a verse of "Amazing Grace" as his daughter, Marsha, smiled and wiped away tears.

Earlier, heart surgeon John Puskas had explained the complexities and risks of the operation to Davis, a lifelong smoker who is overweight, has emphysema and needs supplemental oxygen to sleep at night. Puskas told Davis he was going to take an artery from Davis's arm and veins from his legs, connect them to his aorta and use them to bypass his blocked coronary arteries. He was also going to redirect one of the arteries supplying blood to Davis's chest wall and connect it to his heart. And he was going to do all this while Davis's heart continued to beat. Ironically, this last detail, a radical departure from the traditional protocols of cardiac surgery, didn't bother Davis much at all. "The idea of stopping the heart is scarier than operating on it while it's beating," he said.

Maybe so, but operating on a beating heart is hardly business as usual in America's ORs. According to the Society of Thoracic Surgeons (whose data include up to 80 percent of U.S. procedures), just 28,835 (21 percent) of the 136,897 coronary-artery bypass graft (CABG) operations performed in 2004 were done "off pump," that is, without stopping the heart and rerouting the patient's blood through a heart-lung machine. Up close, the two procedures couldn't be more different. During on-pump surgery, the heart lies there, inert as a piece of raw chicken, while the surgeons work on it. Off-pump, the heart beats and rolls around in the chest like the extraordinary living thing it is. Technically more challenging than the traditional operation, popular with younger surgeons looking for new and better ways to do things (proponents say the benefits include less blood loss, less injury to the heart and quicker recovery time), beating-heart surgery is the cutting edge of the field. "It's a beautiful operation," said Puskas as he artfully stitched Davis's blood-filled coronary arteries.

Not everyone is as enamored with the off-pump procedure as Puskas, who uses it in 95 percent of his cases and has performed the operation approximately 2,000 times since 1996. To stop or not to stop the heart is the hottest issue in cardiac surgery right now. "The camps have formed," says Craig Smith of New York-Presbyterian, who operated on President Bill Clinton's heart and does about 85 percent of his cases off-pump. (Smith decided to do Clinton on-pump after he opened his chest and saw the exact location of his blockages.) Surgeons who prefer the pump, like Timothy Gardner, 66, former chief of cardiac surgery at the University of Pennsylvania, say CABG with the heart-lung machine is the "gold standard" of cardiac surgery and is difficult enough already. "Even when the heart is arrested and stable and not moving and there's no blood in the coronary arteries, it's not a walk in the park," says Gardner. When a report by the American Heart Association last May said both methods were legit and neither was superior, it did nothing to cool the debate.

The key to beating-heart surgery is stabilizing the part of the heart being operated on. This is done with small devices (made by Medtronic and Guidant) that use suction to immobilize the tiny area where the surgeon actually sutures the blood vessels. Even with the technology, surgeons say, it takes some getting used to. "We are trained to operate on a still object," says Puskas. Or, as Smith puts it: "It's a little like learning coronary bypass all over again."

After climbing steadily since the mid-1990s, the number of beating-heart operations has leveled off. Proponents say this is partly due to the lack of a big, randomized trial confirming the benefits of off-pump CABG. Puskas and others have approached the National Institutes of Health about funding such a large (and expensive) study, and Puskas says the response so far has been supportive. Fred Edwards, a surgeon at the University of Florida, who uses the pump in 90 percent of his cases, agrees that a big study will help determine the fate of off-pump. "It's either going to flame out as a fad," he says, "or it's going to go in the other direction."

Meanwhile the experience of patients like Davis will have to suffice. Davis, who was considered too high risk for on-pump surgery at another hospital, was out of bed just six hours after he left the OR and released from the hospital in three days. Reached by phone last week in Athens, Tenn., he was feeling strong, if a little sore. And music was definitely in the air. "I'm jamming again," he said. It's as if he never missed a beat.