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Keyhole Heart Operations Cut Patients' Trauma

FEATURED ARTICLE

The one-and-three-quarter-inch incision under Bruce Tagrin's right armpit looks altogether too small for heart surgery, but Dr. Ralph de la Torre is unfazed, cheerfully maneuvering endoscopes like knitting needles inside the hole as he repairs a leaky valve.

Just a couple of years ago, Tagrin, 48, would have faced a stark choice about his heart defect: Accept steadily declining strength as his heart lost pumping power, or endure a debilitating operation in which a surgeon cut through his breastbone to reach his heart.

Today, though, a 38-year-old surgeon "is basically operating through a keyhole" to stitch up the valve deep inside his chest, said an admiring Dr. Peter Panzica, the anesthesiologist at Tagrin's operation in Beth Israel Deaconess Medical Center.

De la Torre's two-year-old technique reflects the increasing pressure on heart surgeons to make their operations less traumatic for patients. Though heart surgeons remain a! mong the best-paid specialists in all of medicine, with annual incomes often topping $500,000, they are steadily losing patients to cardiologists who can now open arteries and even repair hearts using only local anesthesia.

In response, heart surgeons are developing technically demanding operations that reduce the amount of traumatic cutting or avoid the need to stop the patient's heart during the operation. De la Torre's new mitral valve operation avoids cutting through any bone or muscle, instead reaching most of the way through the patient's chest cavity and tying sutures with 16-inch-long endoscopes, which he likens to "tying your tie through your fly."

"I'm a big fan of his," said Dr. Harold Roberts of South Florida Cardiovascular Surgical Associates, who learned from de la Torre how to do the minimally invasive mitral valve repair earlier this year. Based on results from de la Torre's first 80 operations, the repairs work as well as open heart surgery, b! ut with far less scarring and shorter recovery time. Roberts said that all 20 of his mitral valve repair patients so far have survived, which is better than the survival rate for conventional surgery.

Twenty-five years ago, repair of the heart and its major arteries was largely the domain of heart surgeons, who often endured eight years of training after medical school to enter the high-profile fraternity. Business was booming, thanks to coronary artery bypass surgeries in which surgeons opened the chest and rerouted blood around blockages using veins taken from the arm or leg.

But then came "interventional cardiology," performed by heart specialists who generally had no surgical training. By inserting a catheter through an artery in the arm or leg, cardiologists could ferry in a tiny balloon that, once inflated, clears arteries at lower risk and less cost than bypass surgery. In 1999, the procedure, called angioplasty, overtook coronary artery bypass surgery as the leading procedure to treat coronary artery disease, according to! the American Heart Association.

Since then, cardiologists have only expanded their uses of catheter-based techniques. New drug-coated stents, mesh tubes that prop open arteries and keep them from reclogging, allow them to treat patients with more complex coronary artery disease who used to go straight to the surgeons. In addition, cardiologists are developing techniques to repair the heart itself. One French company, CoreValve, is beginning human trials of an artificial heart valve that can be inserted by a cardiologist through a catheter and then inflated.

No one thinks heart surgery is going to disappear. As baby boomers age, their clogged arteries, leaky valves, and other problems may actually create a shortage of heart surgeons in the next few years. However, heart surgeons are feeling the impact of the drain on business: The American Medical Group Association found that the incomes of interventional cardiologists rose 17.8 percent from 1999 to 2002, to $! 329,494, while surgeons' pay rose just 2.8 percent, to $400,500 a rat e that did not keep up with inflation.

Perhaps more important, many heart surgeons are finding that their work lives have gotten tougher as they see fewer routine coronary bypass operations and more seriously ill patients. De la Torre, in fact, does very few bypasses, concentrating his busy practice on high-risk cases almost exclusively. He loves the work, but freely admits he is in a high burnout profession.

"The people [surgeons] are seeing are sicker," said Dr. Thomas C. Piemonte, chief of the catheterization lab at the Lahey Clinic in Burlington. "Their lives have become much more difficult."

In the long run, de la Torre believes, the rivalry between the two disciplines is good for patients, pushing both sides to improve.

"What's the next frontier? Everyone agrees it's minimally invasive," said de la Torre. "Fifty years from now, we'll look back on what we do now and think it's absolutely barbaric."

With his crew cut and broad shoulders! , de la Torre could just as easily pass for a wrestler as one of Boston's fastest-rising heart surgeons. Promoted to chief cardiac surgeon this year at an age when most surgeons are still honing their skills, de la Torre is also likely to be the first surgeon in Boston to implant an Abiomed artificial heart into a patient, after persuading Beth Israel chief executive Paul Levy to support the high-risk surgery even though the hospital is likely to lose money on the project.

"If anyone in the world should be doing this, it's Ralph," said Levy of the artificial heart, calling de la Torre "our artist."

Several years ago, de la Torre issued a warning that without more innovation in heart surgery, the profession could face long-term decline. At a 2001 conference on minimally invasive heart surgery, an approach that began to catch on in the mid-1990s, he and two other Beth Israel heart surgeons said catheter-based techniques are "significant improvements" for patient! s that should force heart surgeons to improve as well.

Original ly trained as an engineer at Duke University, de la Torre brings a dogged problem-solving approach to surgery. Though other surgeons already did mitral valve repair through small "ports" rather than an open chest, they usually ended up leaving scars on the patient's chest and sometimes cutting through muscle. De la Torre was convinced he could do the operation more cleanly. To perfect his technique, which requires him to go from the right armpit across the chest cavity to the heart on the left, de la Torre spent numerous weekends over the past two years practicing on cadavers.

Tagrin's five-hour operation, conducted earlier this month, could not have gone more smoothly. Through the small incision, de la Torre's instruments cut through the sac that surrounds the heart and revealed the damaged mitral valve, which was so easy to see that another surgeon described it as "lips just waiting to be kissed." And, as de la Torre hoped, Tagrin's valve only needed repair, not tot! al replacement. Tagrin's heart was stopped for a little more than an hour and a half, a few minutes longer than in conventional surgery, but he showed no signs of mental fogginess or other complications associated with being placed on cardiopulmonary bypass.

Three days later, Tagrin, of Randolph, said he was still sore and tired. "Other than that," he said, "I feel great," adding that he was planning to take 10-minute walks in a few days. De la Torre said he should be fully recovered in five to six weeks.

But, even as de la Torre's technique becomes standard at Beth Israel Deaconess, and surgeons elsewhere develop other minimally invasive heart procedures, an interventional cardiologist at Emory University in Atlanta is developing a catheter-based mitral valve repair that would be even less invasive, and would not require stopping the heart at all. Dr. Peter Block uses a catheter to attach tiny clips to the mitral valve, reducing the leak.

"Imagine doin! g the whole thing without having to put the patient on cardiopulmonary bypass," said Block, who has done 25 of the catheter-based valve repairs so far. "Cardiac surgery is not going to go away because of that, but I think what we will do is come to a middle ground where we will all work to do what's best for the patient."

De la Torre agrees, suggesting that catheter-based repairs could be best for patients who are too frail for surgery, while his surgical method may produce more durable repairs for healthier patients like Tagrin who are likely to live longer.

Eventually, de la Torre believes the turf battle between surgeons and cardiologists may end as leaders in the two fields find ways to pool their skills. For instance, Beth Israel Deaconess is planning one of the East Coast's first joint catheterization labs, operating rooms where surgeons and cardiologists can perform hybrid procedures. "The paradigm is shifting where it's not surgeons and cardiologists," said de la Torre. "We are doctors first."