Without Missing A Beat

Cardiac surgeon Glenn Whitman champions a different kind of bypass -- one that doesn't stop the heart or use a pump. It may be easier on the patients but it's more challenging for their doctors

April 12, 1999|By Richard O'Mara | Richard O'Mara,SUN STAFF

The room is large and bright. A dozen people in hospital scrubs move about, gathering themselves to carry the healing craft of heart surgery another step forward. Dr. Glenn J.R. Whitman, chief surgeon, is one of the first in. He's chatty, eager to begin.

The patient is 56-year-old Dave Nally, an industrial welder from Sharpsburg. He has blockages in two arteries. He has been prepped since 8: 35 a.m. for cardiac bypass surgery at the University of Maryland Medical Center. It is now almost 9. He is anesthetized. And a good thing, too.

He is rolled and kneaded, shaved and probed. He is stuck with needles. Black plastic tubing emerges from his mouth; gray plastic tubing circles his thick right arm. His legs are hoisted into stirrups. A nurse paints his body with iodine and wraps him in plastic; it adheres to his skin like a shrink wrap.

A heart-lung machine stands nearby, but it won't be used. It is only a precaution. Today's procedure will be "off pump," that is, without the machine that cardiac surgeons have relied upon for more than 30 years to do the work of the heart while the repair is made. The machine allows the heart to be brought to a dead-stop so it is not moving as surgeons work on it.

But Nally's heart will continue to pump while the two bypasses are sewn into place.

"This," says Whitman, "is the new frontier of cardiac surgery."

It is a procedure virtually unthought of just over a decade ago, and some think it may divide the medical community generationally, with young surgeons taking to it more readily than their seniors. At least Whitman believes it will. He was hired in December as the hospital's new head of cardiothoracic surgery. His mission is to make the University of Maryland Medical Center the place to go to for off-pump bypass heart surgery.

The hospital averages about a thousand heart bypass operations a year. Before Whitman arrived Dec. 7, only five had been performed off-pump. Since then there have been more than 30, two-thirds by Whitman.

Proponents say off-pump is easier on the patients, but operating on the beating heart presents a challenge to cardiac surgeons.

"When you do an operation on a blood vessel off-pump, you stop the blood from going through the vessel while you do your connection of the new vessel," Whitman explains. "During that period of time we are actually stimulating the onset of a heart attack. The blood isn't flowing. We have five to 10 minutes."

If something goes awry while this is happening -- say an arrhythmia develops, or the heart ceases to pump -- the surgeon must quickly put the patient on the machine.

Glenn Whitman had been a cardiac surgeon for nine years when he turned his attention to the new method he now champions. "We all heard about it. We started to hear about it in meetings in connection with the minimally invasive surgery."

He came to the University of Maryland Hospital from the Medical College of Pennsylvania in Philadelphia, where he headed cardiothoracic surgery. He is a lean man with a narrow face.

Whitman likes to emphasize that off-pump surgery is less a new procedure than a return to the way things were done years ago. "There had been heart surgery long before there was a pump," he says.

Yes, but not much of it, and usually unsuccessful. And even then most surgery was performed on infants with congenital heart defects, such as the famous blue babies. These children are born with holes in their hearts and muscular blockages that inhibit the flow of red oxygenated blood to the lungs, an absence of which lends a blue tint to their complexions.

Also there were occasional surgical attempts to pluck shrapnel from the beating hearts of veterans.

"The mortality rate was very high in this," said Dr. Vincent L. Gott, former chief of cardiac surgery at Johns Hopkins Hospital.

The era of widespread open-heart and bypass surgery began with the invention of a machine by the University of Pennsylvania's Dr. John Gibbon in 1955. This machine, "big as a Volkswagen," sought to keep oxygenated blood flowing to the brain and lungs. It was not entirely successful, but it led to more efficient machines, and ultimately to the heart-lung machine used today, which pumps the patient's blood out of the body and back in again, delivering oxygen to the lungs and brain.

This machine, to Gott's mind, "is still the best thing there is. The success rate is around 99 percent."

Then what is gained by operating on a beating heart? Why is it better than using the heart-lung machine?

Because, Whitman says, the machine is bad for you.

"Complications are multiplied by the time on the pump," he says. "Having your blood passed through a plastic tube is not good for you. God didn't make our blood to go through a pump."

Among those complications Whitman counts the occasional swelling of the brain, infections, the need for transfusions, arrhythmia, stress on the kidneys and, occasionally, blood vessel damage caused when inserting the tubes that lead to and from the heart-lung machine.

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