Hey, Doc, Minimize It

Barry Goodman, 46, is a chiropractor, yoga teacher, surfer, kayaker, swimmer, cyclist and father of four who has worked hard throughout his life to stay fit and healthy. Unfortunately, he is also part of a family with a significant history of heart problems. Ten years ago Goodman, of Long Beach, N.Y., began to experience lightheadedness and dizziness and was eventually diagnosed with paroxysmal atrial fibrillation (AF), recurring episodes of irregular and accelerated heartbeat that can cause weakness and even strokes. Medication helped, but the drugs had many side effects, including fatigue, and he would often stop taking the pills. "My healthiest times were on the yoga mat," he says--"I was breathing correctly, I was concentrating. But off the mat I was sluggish and tired." He was hospitalized for the first time in 1999, and after several more bad episodes, including one period of arrhythmia that lasted nine months, he decided to undergo surgery.

As it happened, during the years Goodman was trying to handle the problem on his own, some new, minimally invasive surgical treatments for AF were being developed around the country. Goodman underwent one such procedure last May at Lenox Hill Hospital in New York. During the robot-assisted surgery, Dr. Didier Loulmet used microwave energy to interrupt the electrical pathways in Goodman's heart that were causing his AF. "I have four little one-inch scars," says Goodman, who has had no episodes of arrhythmia since the operation and is getting stronger every day. "They didn't have to rip me open; I had nothing cracked. I do believe that I owe my life to this team of doctors and their work with this robot."

There is nothing in medicine quite so invasive as traditional open-heart surgery. In a typical operation, the chest cavity is sliced, sawed and then split open, the circulation is rerouted through a heart-lung machine, the aorta is clamped shut and the heart is stopped as the surgeons make their repairs, cutting and sewing on the most important muscle in the body. To someone watching it with a layman's eye, it's hard to believe anyone could survive such a graphic dissection, never mind benefit from it. Of course, hundreds of thousands of Americans do benefit from open-heart surgery every year; the mortality rate for routine coronary-artery bypass grafting (CABG), the most common procedure, is approaching 1 percent. But even as open-heart surgery remains the gold standard of care in the United States, a growing number of doctors and medical centers are offering heart patients new options that involve much less wear and tear on the body. In addition to treating AF, these minimally invasive procedures are being used for coronary-artery disease, valve disorders, aortic aneurysms and even heart failure.

The primary goal of minimally invasive heart surgery is a simple one--to reduce suffering. "Patients are mainly concerned about pain, because surgery is associated with pain," says Dr. Randall Wolf, president of the International Society for Minimally Invasive Cardiothoracic Surgery (ISMICS). "So the hope is, if we can make smaller incisions we can lessen or eliminate the discomfort." There is also an economic factor. After most open-heart surgery, the heart itself is good to go, but the patient remains in the hospital recovering from the trauma of the operation. The faster recovery and shorter hospital stays associated with minimally invasive procedures are a plus for patients and, potentially (once the added costs of training, technology and longer OR sessions have been absorbed), for hospital bottom lines as well.

When it comes to minimally invasive heart surgery, Dr. Valavanur Subramanian, chairman of cardiothoracic surgery at Lenox Hill and a founding member (in 1997) and past president of ISMICS, gets about as enthusiastic as a surgeon might be expected to get. Which is to say, he talks fast and a lot about his favorite subject and says some amazing things. For example: "With this procedure we are paving the way for out-patient bypass." The procedure he's referring to is his specialty--robot-assisted, minimally invasive direct coronary-artery bypass, a.k.a. robotic MIDCAB. It's surgery in which he bypasses from one to four blocked coronary arteries while operating via robot (Intuitive Surgical's da Vinci system) through one 2-inch incision and two small holes, without spreading the ribs and without stopping the heart. Though MIDCAB (with and without the robot) accounts for just a tiny fraction of the more than 300,000 bypass operations performed annually in the United States, and usually involves just one or two arteries (Subramanian's experience enables him to do more), he is confident that the procedure will catch on with surgeons and the public alike, because it works so well. Subramanian has sent patients home as soon as 14 hours after surgery, he says. "One of them drove the car himself when he left," he adds.

Another bypass technique, called off-pump coronary-artery bypass (OPCAB), which accounts for about 20 percent of all bypasses, is considered less invasive because, though the chest is opened, the surgeon operates on the beating heart and the patient is not put on the heart-lung machine. Among other things, this reduces the risk of stroke and shortens recovery time.

While Wolf recognizes the importance of MIDCAB and OPCAB, he thinks bypass procedures are the wrong measure of minimally invasive surgery's current popularity and future promise. "There's been a lot of emphasis on bypass surgery, because when you do your business plan that's where the numbers are," he says. "But there are many exciting technologies that do not deal with bypass surgery that have great potential."

An estimated 2.2 million people in the United States have AF, and about 300,000 cases are diagnosed each year. Not all of them are candidates for surgery, notes Wolf, but if even a third of them are, then hundreds of thousands of people would stand to benefit from these rapidly evolving techniques. (Open-heart surgery has rarely been used for stand-alone AF.) Wolf has developed his own AF technique called the Mini-Maze. He performs it through two small incisions, one on each side of the chest, and applies a clamp that delivers a bipolar radio frequency to the heart, creating a lesion that blocks the errant impulses that cause AF. The clamp touch-es the heart for just eight seconds. "Eight seconds means one doesn't have to use heparin [to prevent clots] or stop the heart," says Wolf, director of the University of Cincinnati's Center for Surgical Innovation.

Not all heart-surgery patients are suitable candidates for minimally invasive procedures; it depends on the individual's anatomy and condition. And not all surgeons are interested in doing them. Even so, besides being used for AF and bypass, minimally invasive techniques are now employed to replace and repair mitral valves inside the heart and to treat heart failure by remodeling the ventricle. In both of these procedures, while the incisions are minimal, the heart-lung machine is used. In addition, progress is being made in the minimally invasive treatment of thoracic aortic aneurysms, potentially deadly weaknesses in the large blood vessel at the top of the heart. And ISMICS has launched an initiative to train residents in the techniques.

If minimally invasive heart surgery is to gain wider acceptance, there will likely have to be large, multicenter clinical trials comparing the new techniques with conventional surgery and established interventions like angioplasty. The studies so far have been small and, because of rapidly changing methods and technology, sometimes dated by the time they are published. "You get the data at the end of five years and people say, 'Yes, but our tools are all different now'," says Dr. James Fonger, who will assume the presidency of ISMICS next summer. "In the first 10 years of development a new field is very dynamic, with a high state of evolution, which makes it something of a moving target." And, for patients like Barry Goodman, something of a godsend as well.