Beating-Heart Surgery May Reduce Complications, Deaths

A study released in 2003 showed a significant reduction in death rates from coronary bypass surgery among patients whose hearts were kept beating during the procedure, and also indicated fewer strokes and other surgery complications when the "beating-heart" technique was used.

For the trial involving more than 900 high-risk patients, researchers from New York University Medical Center compared data from two types of bypass operations. In the traditional approach, employed by more than 80% of US cardiac surgeons, the heart is stopped and a heart-lung machine pumps blood and oxygen to the body. In the beating-heart approach, specific areas of the heart are immobilized with special equipment but the heart continues to beat during surgery.

Data on the beating-heart approach had been limited to patients with low risk of death from coronary bypass surgery until the completion of the study, which was the first to focus on high-risk patients. The news that both high- and low-risk patients may benefit generated widespread media reports about the beating-heart procedure. Great public interest has also been fueled by advertising campaigns by some hospitals promoting their use of the "new" technique.

Technique Not New, But Improved
"Beating-heart surgery is nothing new," said G. Hossein Almassi, MD, Medical College of Wisconsin Professor of Cardiothoracic Surgery. "When cardiac surgery started early on in the 1950s and 1960s, surgery was done on the beating heart. And when coronary bypass surgery started in the 60s, it was also done on the beating heart.

"Subsequently, because of the availability of the heart-lung machine, surgeons saw that working on a heart that was not beating was easier so they went in that direction. There was a resurgence of interest in beating-heart surgery in the US around 1994, based on the experience of South American surgeons who, I think mainly for economic reasons and the expenses associated with the use of heart-lung machines and other expensive technology, continued to do beating-heart surgery."

"In the beating-heart approach, when we expose the heart we use devices that stabilize the area where we are going to put the graft to the coronary artery," said Dr. Almassi. "Although the rest of the heart moves, this limited area of, let's say, and inch and a half in length, is for practical purposes motionless. It's not completely motionless, but it's not moving like the rest of the heart."

Roughly nine out of every ten coronary bypasses at Froedtert & Medical College are beating-heart procedures, Dr. Almassi said. Some patients are not good candidates for beating-heart surgery, he noted, in particular those with large hearts and very bad heart function and those with extraordinary pressure placed on the heart because of conditions such as a caved-in chest wall, a deformity of the breast bone that can be very severe in some individuals.

Nationwide Study Underway
Patients in the NYU Medical Center trial who had bypass surgery with their hearts beating had a death rate of 6.5%, compared to a death rate of 11.4% for those whose hearts were stopped. Just 1.6% of the beating-heart patients experienced strokes, compared to the 5.7% in the traditional-surgery group, and 92% of the beating-heart patients had no surgery complications at all compared to 80% of the other patients who were complication-free. Many other studies have been conducted related to different aspects of beating-heart surgery in recent years.

"When you look at all the studies together," said Dr. Almassi, "it appears that there is less problem with bleeding and less need for transfusion (when the beating-heart technique is used)." Other than that, he said, the relationship between beating-heart surgery and rates of post-surgical blockage of grafted arteries, incidence of arrhythmia and heart attacks, stroke rates and non-stroke neurocognitive impairment, length of hospital stay and other cost ramifications, and other issues have not yet been examined fully enough.

In order to provide more definitive conclusions in those and other areas, Dr. Almassi and colleagues at the Medical College and elsewhere are taking part in a tightly controlled nationwide study of 2,200 coronary bypass patients who undergo surgery at Veterans Administration hospitals. Subjects in this study will all have follow-up angiograms one year after their surgery; data from the study should be available by the year 2007. Dr. Almassi said that such large-scale research will be of great value in determining the overall efficacy of beating-heart surgery.

Dan Ullrich
HealthLink Contributing Writer

MCW Health News presents up-to-date information on patient care and medical research by the physicians of the Medical College of Wisconsin.