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an online version of the magazine Spring/Summer 2005
Features
Change of Heart  
 
  With cardiac bypass operations on the wane, three young surgeons here are using techniques straight out of science fiction to attack other once-fatal heart maladies.
BY MARY ANN AYD
 
 
 
 

At 77, George Massie had little interest in having his breastbone sawed open. It wasn't that he failed to appreciate the risk of not having the operation. But until his cardiologist sent him to David Yuh, Massie knew of only one way a heart surgeon could reach the leaking mitral valve that was steadily weakening his heart. The very thought of subjecting himself to the ribcage-splitting incision and its long, painful aftermath left the Fort Washington, Md., resident cold. Without the alternative Yuh offered, says Massie, "I probably would not have gone through with it."

What got Massie to yes was Yuh's description of a seeming oxymoron: closed-chest open-heart surgery. Instead of taking the traditional, through-the-chest route into the heart, Yuh could gain access to the “intake valve” that lets blood enter the left ventricle by making three small incisions in Massie's side. Into these between-the-rib ports, Yuh would ease a tiny but powerful high-resolution video camera and two slim arms with pincer-like “fingers” at their ends. Then, sitting at a console a few feet away, Yuh would operate with his robotic “eyes” and “hands” to repair Massie's malfunctioning heart valve.

Though he was still nervous, Massie signed on for the much-less-invasive procedure. The day after his operation he was up and walking; a week later he was home—in time for Christmas, just as Yuh had promised. Even more impressive, Massie says, “I had no pain. That prescription is still on my dresser.”

Try telling patients like Massie—or cardiac surgeons like Yuh—that a specialty considered a pipe dream 50 years ago has already stagnated and faces a dim future.

Yet that's precisely the sentiment Bill Baumgartner confronted head-on in 2003 when he stepped into the presidency of the Society of Thoracic Surgeons, the professional organization that includes both chest surgeons, who operate on the lungs and esophagus, and cardiac surgeons, who operate on the heart and great vessels. Addressing the group's annual meeting, Hopkins ' cardiac surgeon in chief pulled no punches about some of the speed bumps his profession has been bouncing over in recent years.

Between 1999 and 2001, for example, there was a 14 percent decrease in the number of U.S. coronary artery bypass operations, the most commonly performed cardiothoracic procedure. The drop-off was fueled in part by the growing use of less-invasive interventions, such as angioplasty and stents, to unclog blood vessels. And with the introduction two years ago of drug- coated stents that do a better job of keeping opened vessels from narrowing again, bypass operations quickly plummeted another 14 percent.

And though the number of other heart operations such as valve repairs has remained relatively steady, fewer of the nation's graduating medical students have been willing to invest in eight or more years of training if overall there's dwindling demand for their hard-won skill. In 1996, 155 students chose cardiothoracic surgery; in 2001, there were 110, and some hospitals couldn't fill all their training slots. Even with this winnowing, however, some cardiac surgeons say their ranks are still too full.

 

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But Baumgartner, who arrived at Hopkins in 1982 to launch the heart and heart-lung transplant program, isn't buying the notion that a few numerical blips mean cardiac surgery has nowhere to go.

“I do believe we're in an odd hiatus,” says the soft-spoken Kentucky native, “that's due to a confluence of economic factors.” Reimbursements to the physicians performing these complex procedures are 48 percent less than they were a year ago. Additionally, the post-9/11 market slide prompted a number of veteran cardiac surgeons to postpone retirement. The resulting glut made it difficult for some new cardiac surgeons to find jobs. But Baumgartner points to one major factor that's leading manpower forecasters to predict that specialists will be in short supply in 20 years, and which is also prompting the Association of American Medical Colleges to ask for an increase in both medical students and medical schools: The population is aging. “I predict,” Baumgartner says, “that 10 years from now there's going to be a plethora of cardiac problems.”

For Baumgartner, though, the issue runs deeper than supply and demand. Having created open-heart surgery, heart and lung transplants, operations for aortic disease, arrhythmias and complicated congenital heart defects, why, he asks, would we stop here? Why view a declining need for bypass procedures as anything but a primo opportunity to tackle new territory? Heart failure, for example, already affects some 5 million Americans and claims the lives of 300,000 each year—more than breast, colon, lung and pancreatic cancer combined. This breakdown of the heart's ability to pump blood, which leaves victims struggling to breathe, is expected only to increase—at the rate of 400,000 to 600,000 cases annually. Another 3 million people have the rapid, irregular contractions of heart muscle fibers known as atrial fibrillation. Already, the future surgical treatment for these and other conditions looks extremely promising, says Baumgartner. “We just need to keep doing what we've always done: develop innovative operations.”

To prove his point, Baumgartner need only walk into his own operating rooms and watch a trio of young heart surgeons he's added to his faculty over the last few years. “People don't believe me,” Baumgartner says, “but it really is pure serendipity that John Conte, David Yuh and Luca Vricella all trained at Stanford.”

In 1998, looking for someone to “push the limits of heart and lung transplantation,” Baumgartner was thrilled when John Conte came knocking. Like Baumgartner had nearly a generation earlier, Conte learned heart surgery under Norman Shumway, the Stanford surgeon who pioneered heart transplants in the late 1960s. There was no doubt in Baumgartner's mind that Conte was the right choice to take over leadership of the heart and lung transplant team here.

Since then, Conte has not only continued his research on ways to preserve always-scarce organs for transplant, he's helped make Hopkins one of the country's premier institutions for heart failure patients, especially those who are too old or too sick to undergo a transplant, even if a donor heart were available. Under his leadership, it's become the only U.S. institution offering training in ventricular restoration, an operation that reshapes the heart and improves its ability to pump blood. Conte was also among the first in his field to embrace the new breed of implantable heart devices that serve not merely as a bridge to transplant, but now as a substitute.

“I think every patient should be involved in our research,” says the 46-year-old. “That doesn't mean experimenting on them, but hoping they'll leave a little bit of themselves behind so that we can come up with the new treatments that will benefit not only them, but the patients who follow.”

Luca Vricella and John Conte are both using new kinds of implantable devices to keep desperately ill heart patients alive.  
> Luca Vricella and John Conte are both using new kinds of implantable devices to keep desperately ill heart patients alive.

In 2002, Luca Vricella became the newest recruit to join this pioneering effort. Baumgartner brought him aboard to help 15-year veteran Duke Cameron, the pediatric cardiac surgeon whom Baumgartner calls “the most talented surgeon in our group,” with his growing caseload.

A switch hitter who's equally adept in the adult operating room, Vricella was a 10-year- old in his native Italy when he flipped on a black-and-white TV in 1975 and became mesmerized watching an open-heart operation. “I thought, this is just absolutely fantastic. So I grew up thinking I was going into cardiac surgery.” Along the way, he collected an impressive roster of mentors, including Leonard Bailey of Loma Linda University (famous for transplanting a baboon heart into Baby Fae in 1984), and Bruce Reitz (former chair of cardiothoracic surgery at Stanford and Hopkins who to this day Baumgartner counts among his closest friends).

Given Vricella's credentials, no one was surprised when, early this year, he proposed trying a cardiovascular support system called the Berlin Heart—so new it's been used less than a dozen times in the United States—for a baby whose restrictive cardiomyopathy was preventing her heart from filling with blood. Existing implantable pumps are sized for adults, and the only alternative for children is extracorporeal membrane oxygenation, a modified form of heart-lung bypass that requires patients to stay bedridden and immobile. The Berlin Heart provides a better quality of life while the child awaits a transplant.

Still, perhaps the most unusual ingredient in Baumgartner's new cardiac surgery recipe is the 41-year-old Californian who joined the team four years ago. A perfectionist who thrives on technology, David Yuh shows patients their angiograms on the plasma screen that dominates his office. “I ask them to point to where they think the problem is,” he says. “When they see the blockages, it makes them believe.”

Until David Yuh was a sophomore in college, his career path had seemed etched in stone. His father, who emigrated from Korea in 1951, had zipped to the top of his class at MIT and Caltech, and frequently let his young son play in his lab while he was working on his Ph.D. in electrical engineering. The toys Yuh grew up with in the late 1960s and early 70s were computer electrical components and a construction set his father brought home that showed what commands do inside a computer.

Yuh was still in high school when he wrote the code for a computer video game that took the world by storm. But of the millions of dollars in royalties he earned from that game—except for paying for his education and a home for his parents—he's given nearly all of it to charity. “By my late teens, I felt partially responsible for the devolution of video arcades into a big problem,” he says. “I've tried to make up for that by donating to programs for young people.”

During his second year at Stanford, majoring in—what else?—computer science, Yuh happened into a very different world. “The life experiences of the pre-med students seemed to me to be so much richer,” he says, “and I began to realize how much I was attracted to what they were interested in, how fascinating it was to see how biology related to human physiology. By the end of that year, I joined them. I felt like a weight had been lifted.”

Following medical school at Stanford, Yuh headed to the University of Minnesota for general surgical training, unaware that his childhood immersion in engineering was about to reassert itself. “I was interested in abdominal organ transplant, but every time hearts came up, I volunteered,” he says. “To me, the heart is more intuitive to understand. It doesn't operate via chemical pathways like the liver or kidney. It's a pump. It moves. Engineers like to see things that move.”

 

*****

 

After three years in the Twin Cities, Yuh returned to his California alma mater, a bit intimidated by the esteem in which cardiac surgery is held at Stanford, but soon feeling at home. “Their training philosophy is, Let the resident do the case, not just watch or assist the senior surgeon,” Yuh explains. “They walk you through every step, every stitch. There are different ways of handling most operations, but their idea is to make each one as doable for a novice as possible. That's the Shumway legacy: You gain confidence, and Shumway's reward has been seeing his trainees become leaders in the field.”

Being in the heart of Silicon Valley at the close of the 20th century also put Yuh literally across the street from another group of innovators, the engineers at a company called Intuitive Surgical, who were fine-tuning a computer-assisted surgery system using advanced robotic technology. The goal at Intuitive was to overcome current limitations posed by minimally invasive operations—invariably, the technology restricts the range of motion for the surgeon who wields the instruments and offers only a two-dimensional view of the operating field. Yuh was excited when Intuitive invited him to serve as a consultant.

Yet it was far from clear even five years ago whether the robotic technology could be made to equal the highly skilled hands of a heart surgeon performing a traditional open operation. For one thing, despite its much-enhanced 3-D views and the ability to eliminate hand tremor, the robot provides no sense of touch: Surgeons must rely solely on their eyes to judge how tautly they can suture, for example, without harming vulnerable tissue. Since the Food and Drug Administration had yet to approve the device for any cardiac procedure, “Do you have a robot?” wasn't on Yuh's list of questions as he contemplated where to launch his professional life.

In 2001, on the verge of joining the faculty at Washington University in St. Louis , Yuh was surprised by an unexpected phone call. “I don't know where you are with your decision,” he heard Hopkins ' cardiac surgery chief saying, “but if you haven't signed yet, come and see us.”

“I agreed to visit on a whim,” Yuh says. “But all you have to do is spend one hour with Dr. Baumgartner and you're like, OK, I'm in.”

Given the wide-ranging and medically complex cases the cardiac surgery division here handles week in and week out, Baumgartner wanted to bring on another surgeon with the capability to lead, assist with or teach virtually any adult heart operation, including transplants. And with a new generation of ventricular assist devices and pacemakers then lining up for take-off, Baumgartner also wanted someone with an unusually high degree of technological savvy. The fact that Hopkins was one of only a handful of medical centers already using Intuitive Surgical's robot for abdominal procedures didn't come up in his conversations with Yuh, but once Yuh settled in here, it didn't take him long to discover that the Intuitive robot he'd come to know in Palo Alto had a twin in Baltimore.

“Why don't you try that?” Baumgartner suggested.

If Yuh ever second-guessed his instinct to throw his lot in with Baumgartner, that simple question cemented the deal. “He's always encouraging us to collaborate and to explore new things,” says Yuh. “With most cardiac surgery chiefs, their own faculty have to make an appointment to see them. We just walk in.”

In the four years since Yuh moved east to Baltimore , he's done a lot. In the fall, he married Bonnie Hiatt, an interventional cardiologist now in private practice here, whom he met in 2000 when they were both nearing the end of their training at Stanford. And among surgeons, he's become known for using new approaches to solve complex problems. In 2003, for example, he found himself drawing on research he'd done with pregnant sheep to successfully replace an expectant mother's malfunctioning aortic valve without injuring her unborn child.

David Yuh:  To me, the heart is more intuitive to understand.  It's a pump.  It moves.  
> David Yuh: "To me, the heart is more intuitive to understand. It's a pump. It moves."

 

 

*****

 

What attracted Yuh to the surgical robot becomes evident the moment you enter his meticulously appointed office on Blalock 6. In this typical sliver of Hopkins real estate, the confines are blurred by intensely royal-blue walls that envelop a space of feng-shui spareness. Not so much as a stray paperclip is allowed to disrupt the balance.

“If there's one lesson I took away from learning to write computer algorithms,” Yuh says, “it's that they have to be perfect. That's what the great programmers achieve, and that's what successful heart surgeons pursue. I saw the robot as a device that could help achieve that kind of precision. It doesn't get tired. It does what you say all the time.”

But, as with all laparoscopic surgery, using the robot flies in the face of conventional wisdom that large incisions give surgeons the best access to what they need to work on. Although the number and scope of minimally invasive operations has increased significantly since 1987— when the first report describing gallbladder removal through “keyhole” incisions appeared—even so-called simple procedures are trickier and more time-consuming than their conventional counterparts, when cameras, indirect routes and long instruments are involved. Because time is especially critical in cardiac operations—like valve repairs and other procedures that require patients to be on heart-lung machines—getting to the heart via mini-incisions has presented significant challenges. The robotic technology, with its easier-to-maneuver small instruments, better visuals and ability to reproduce the dexterity of the human wrist, has overcome some obstacles. Even so, learning to operate with the robot requires persistence and determination to achieve the same results that can be expected with a standard, open approach.

Yuh, true to his engineering roots, hasn't been content merely to master the robotic moves to suture a pacemaker lead on a beating heart, close an atrial septal defect or do coronary artery bypass grafts. He's joined forces with yet another Stanford alum, Allison Okamura, an assistant professor in the University's mechanical engineering department, to close in on ways the robot can let surgeons know precisely how much force they're applying.

“Everything about this kind of surgery is different,” Yuh says, “from handling the tissues to tying the knots. With the robot, you're not scrubbed in, you're not wearing gloves, you don't even have to be in the same room with the patient.”

But that's not the way Yuh operates. On the December day he restored George Massie's malfunctioning mitral valve, Yuh took care to position the robot console close enough to the operating table so that he could glance up from working the controls and see for himself how his patient was doing. As a double safeguard that everything would progress well, stationed at Massie's side throughout the procedure was Yuh's assisting surgeon—Bill Baumgartner.

Meanwhile—as though the day itself was meant to produce a snapshot of cardiothoracic surgery at its finest–in the OR just next door, John Conte was engrossed in transplanting a heart, while one door down, Luca Vricella was transplanting a lung into a 61-year-old with end-stage chronic obstructive pulmonary disease.

I think,” Yuh says, “that Dr. Baumgartner had a bigger vision than we ever realized.”

 
 
 
 
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 Change of Heart
 Irrepressible Dr. De
 The Heat Is On
 
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