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Clinton to Undergo Follow-Up Chest Surgery

Procedure to Remove Fluid, Scar Tissue Not Considered Life-Threatening

By David Brown
Washington Post Staff Writer
Wednesday, March 9, 2005; Page A02

Former president Bill Clinton will undergo surgery tomorrow to remove fluid from around his left lung and take out scar tissue that is causing the fluid to accumulate.

The condition, called a pleural effusion, is causing the former president mild pain and is making him winded when he exercises, his physicians said. It is a rare and non-life-threatening complication of open-chest surgery.

Former president Bill Clinton had heart bypass surgery last September. (J. Scott Applewhite -- AP)

Former president Clinton discusses his health during an appearance at the White House to present a report on tsunami relief.

Clinton, 58, had coronary artery bypass surgery last September at New York-Presbyterian Hospital/Columbia University Medical Center.

"This is an elective procedure. This is not an emergency," Allan Schwartz, Clinton's cardiologist, said at a news briefing.

In Washington yesterday, Clinton told reporters, "I feel fine." He visited the White House with former president George H.W. Bush to brief President Bush on their efforts to generate donations for tsunami relief programs in South Asia.

The problem was diagnosed before Clinton and the elder Bush visited the stricken area last month. Clinton knew at the time he would probably need surgery, one of his physicians said. Neither that trip nor his activities this week are likely to worsen the condition. Clinton plans to play golf today at a charity event in Florida and said he expects to be back at work in several weeks.

The operation will take one to three hours, depending on the size and location of the "pleural peel" -- the scarred, thickened membrane over the lung -- that needs to be removed. This so-called decortication procedure will be performed by Joshua R. Sonett, a thoracic surgeon.

The peel is compressing the lower lobe of Clinton's left lung. That, in turn, has diminished his breathing capacity by about 25 percent, said Craig Smith, the surgeon who performed his bypass operation. Clinton, who lives in Chappaqua, N.Y., walks about four miles a day as part of a rehabilitation program and first noticed his symptoms while going up hills.

When the surgeons are done, they will temporarily place a plastic tube into the pleural space between the outside of the lung and the inner wall of the chest cavity to drain fluid into a device resembling a vacuum bottle. After several days, the tube will be removed. When the lower lobe of the lung reinflates, the surface where the peel was removed will become attached to the inside of the chest cavity, essentially tacking it down.

"They will be taking out bad scar and leaving the conditions for good scar to form," said John G. Byrne, chairman of cardiac surgery at Vanderbilt University Medical Center. He added that he is not familiar with the details of Clinton's case.

The former president could be hospitalized for as many as 10 days, although his stay is likely to be much shorter, the New York doctors said at the briefing.

"This is a relatively low-risk procedure. We expect him to return to full function," Sonett said.

The fluid compressing Clinton's left lung is produced by low-grade inflammation in the plastic-wrap-like membrane covering the lungs, called the pleura. The inflammation is almost certainly the result of the trauma of chest surgery. The fluid comes from the watery part of the blood and is not infected.

Pleural effusions occur in about 90 percent of people in the week after bypass surgery, usually in the left lung. A month after surgery, about half of patients still have them, but in almost all cases they eventually disappear as the body reabsorbs the fluid.

When effusions are large or persistent, physicians sometimes remove the fluid with a large needle inserted between the ribs. This was not tried in Clinton's case, apparently because the scarring was too extensive to solve the problem by removing the fluid alone.

Thickening of the pleura is more common when surgeons use a blood vessel in the chest called the internal mammary artery to create the coronary bypass than when they use a vein from the leg. Clinton's surgeons used the internal mammary artery, which is generally more durable than a leg vein.

Pleural effusions that persist for months, compress a quarter of the lung volume and require surgery are uncommon. Smith said that only about 10 of the 6,000 patients in his clinical experience have needed the operation Clinton will have. A study from Saint Thomas Hospital in Nashville and Vanderbilt University in 1999 found that just under 1 percent of 3,700 patients studied developed the complication.

Schwartz, Clinton's cardiologist, said his patient passed a treadmill stress test "with flying colors" before the recent trip to South Asia. That indicates the bypass operation was a success and has restored adequate blood flow to the heart muscle.

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