A Gentler Approach To Heart Surgery

HORACE STONE IS A MINOR CELEBRITY around Roswell, Ga. No one was surprised last fall when the retired AT&T manager had to go in for a bypass operation; he had already been through a heart attack and two angioplasties when his chest started aching again. What impressed people was his recovery. Instead of spending a week in the hospital and three months gaining the strength to dress himself, Stone walked out of the hospital in three days. Two weeks later he was playing golf. Stone's internist was flabbergasted when he showed up for an appointment sporting a three-inch cut in place of the traditional foot-long chest wound. And when the story spread through Stone's church, folks started calling from as far away as Florida to learn his secret. Not that he minded. ""I would recommend this treatment to anyone,'' he says.

Stone owes his notoriety to Dr. William Mayfield, an Atlanta surgeon who is pioneering alternatives to traditional open-heart surgery. In a standard coronary- bypass operation, surgeons sever the patient's breastbone with a saw, pry open the rib cage with a steel retractor, then stop the heart cold while they reconfigure its supporting blood vessels. Mayfield and other surgeons are learning to do the same job with instruments they can slip through tiny ""keyhole'' incisions between the ribs (chart). Their techniques vary--some surgeons stop the patient's heart, while others leave it beating--but all avoid massive damage to the chest. And as Horace Stone discovered, that means less pain, smaller hospital bills and far quicker recovery. ""This is the biggest advance in heart surgery in 20 years,'' says Dr. Greg Fontana of Cedars-Sinai Medical Center in Los Angeles. ""It's turning the whole field upside down.''

The most versatile of the new techniques, developed by the Heartport company of Redwood City, Calif., is also the least radical. Surgeons using the firm's Port Access system still stop the patient's heart and use a heart-lung machine to maintain circulation while they go about their work. But instead of attaching the machine's hoses directly to the surface of the heart--a procedure that requires exposing the whole organ--they pass them through blood vessels in the neck and groin. Once those connections are made, many valve and artery repairs can be performed through a three-inch incision over the heart. At most, the surgeons may slip a few probes between the ribs or clip a small piece of one rib.

Stopping the heart may enhance a surgeon's control, but the heart-lung machine can cause complications ranging from lung and kidney failure to brain damage and stroke. To avoid those problems, some surgeons are exploring a more radical alternative to open-chest surgery: they're operating while the heart continues to beat. Mayfield, the Atlanta surgeon who worked on Horace Stone, uses a handheld claw to pin down a section of the beating heart while he works on it through keyhole incisions. Other surgeons have designed comparable tools, and several companies are racing to market them.

The new approaches won't eliminate open-heart surgery, but they could save a lot of blood and money. Some surgeons predict that techniques like Port Access will one day handle up to 75 percent of the half-million open-heart operations performed in this country each year. At the New York University Medical Center, surgeons are already using it to perform valve replacements and multiple-vessel bypass operations.

The beating-heart procedure is intended mainly for single-vessel bypass operations, which are far less common. But Mayfield believes it could replace many of the 300,000 angioplasties that U.S. cardiologists now perform annually. Angioplasty is an outpatient procedure that lets many people with single-vessel blockages bypass the scalpel completely. A cardiologist opens the clogged artery by running a balloon-tipped catheter through it. The catch is that a third of all angioplasties fail within six months, while most bypass grafts work for more than a decade. A series of angioplasties may have been preferable to an old-fashioned heart operation, but the new procedure could change the calculus. ""I just saw a patient who'd had four angioplasties in 12 months,'' says Mayfield. ""My operation would have cost less.'' And judging by Horace Stone's experience, it wouldn't have been much more traumatic.

A Gentler Approach To Heart Surgery | News