A Kinder, Gentler Heart Bypass

While taking her daily walk last summer, Lucille Biery's arm went numb, and

her chest felt so heavy she had to sit on the curb. The 69-year-old retired cafeteria worker from Texas City, Tex., went to an emergency room, where doctors told her she needed immediate heart-bypass surgery. But Biery, remembering how her mother "was laid up for months and months" after the same procedure 10 years ago, opted for a new, less traumatic operation called keyhole surgery. Two days later, she was out of the hospital--and after a week, she was taking short strolls. "That's medical progress for you," she says.

For the 57 million Americans who suffer from coronary-artery disease, keyhole surgery offers a gentler form of treatment. The disease, the leading cause of death in the U.S., occurs when fat-like plaque builds up in arteries supplying blood to the heart. When arteries become clogged, the heart is denied oxygen, causing a heart attack.

ENTHUSED. Surgeons commonly treat blocked arteries by taking vessels from another part of the body and grafting them onto the heart. This allows blood to travel around the obstructed arteries. Unlike traditional bypass surgery, which involves making a 12- to 15-inch incision in the chest and sawing open the breastbone to spread apart the rib cage, the keyhole technique requires a mere 3- to 5-inch incision.

The less invasive procedure sounds preferable. But is keyhole surgery better than the traditional method? While doctors are enthusiastic, they hesitate to proclaim its superiority over conventional bypass surgery. "There is just not enough data to suggest that one way is better than the other, or that they are even equivalent in terms of risk to the patient," says John Baldwin, chairman of the department of surgery at Baylor College of Medicine in Houston.

Nonetheless, health insurers readily cover keyhole procedures because they generally cost about one-third less than a standard bypass, which can run $25,000 to $50,000. Although keyhole surgery takes three hours to perform, twice the time surgeons need for a conventional operation, patients leave the hospital quicker, which accounts for the savings. Research also indicates that keyhole patients lose less blood, experience less pain, and have faster recoveries.

Indeed, Michael Sweeney, chief of cardiovascular surgery at Houston's Hermann Hospital and the doctor who operated on Biery, considers nearly any patient needing bypass surgery or heart-valve replacement a candidate for the keyhole approach. He excludes those with vascular problems that might interfere with his ability to insert the tubing required to perform the procedure.

Since keyhole surgery is not yet widely performed--only 100 doctors do the operation nationwide--its long-term effects have yet to be determined. So far, the most common problem is that the complication rate, as measured by the success of bypass grafts, is 7% to 9% higher than with conventional bypass surgery. That should improve as surgeons "come out of the learning curve," says Timothy Gardner, chief of cardiothoracic surgery at the Hospital of the University of Pennsylvania in Philadelphia.

TUBING. In performing keyhole operations, surgeons rely on specially designed tubes and elongated instruments. Doctors start by threading thin, flexible tubing through tiny incisions in the patient's neck and groin until they reach the heart. These tubes drain blood and deliver medication that stops the heart. At this point, a heart-lung machine provides circulatory function.

The next step is to make the small cut just below the breast. Surgeons remove a bit of cartilage from between two ribs to provide a "keyhole to peep through," says Sweeney. Through this window, surgeons use long instruments to create a bypass channel with an artery extracted from the area surrounding the heart. "This is an exciting new development that will revolutionize the way we treat coronary artery disease," says William Cohn, cardiothoracic surgeon at Beth Israel Deaconess Hospital in Boston. That's enough to quicken anyone's pulse.

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