For Heart Disease, a Joint Effort

University of Maryland Medical Center doctors have combined these two approaches for opening clogged heart vessels.
University of Maryland Medical Center doctors have combined these two approaches for opening clogged heart vessels. (Source: New England Journal Of Medicine, May 26, 2005)
By Naseem Sowti
Washington Post Staff Writer
Tuesday, July 5, 2005

Bypass surgery and angioplasty, often seen as opposing approaches to treating blocked blood vessels in the heart, are being combined in a single, minimally invasive procedure at the University of Maryland Medical Center (UMMC) in Baltimore.

The technique, called the simultaneous hybrid procedure, puts heart surgeons and interventional cardiologists, two types of specialists sometimes in conflict over the best approach to treating serious heart disease, in the same operating room at the same time.

"Coronary artery disease can be treated in two ways," said Robert Poston, who performs the bypass portion of the hybrid procedure at UMMC. "We're combining the best of both worlds." The procedure is safer and more efficient and shortens the patient's hospital stay, he said.

Others are less enthusiastic about the innovation.

"There's no convincing evidence that the hybrid procedure is superior," said Stuart Seides, assistant director of cardiology at Washington Hospital Center, one of the largest and most advanced cardiac care centers in the country. It is not considering the hybrid procedure.

The simultaneous hybrid procedure was first reported in 1996 in Germany, but it never became popular and only a few small studies were published about it thereafter.

During the hybrid procedure, the cardiac surgeon opens a 2 1/2 -inch incision under the patient's left breast and bypasses the clogged main artery of the heart, called the left anterior descending artery (LAD), by using a blood vessel taken from elsewhere in the body.

Then the interventional cardiologist steps in to treat the smaller clogged arteries. Using a catheter that is threaded into the blockages, the physician implants stents -- metal scaffolding -- to keep the blood vessels open.

Sixty-three-year old Pearl Walker of Waynesboro, Pa., was having a heart attack when she arrived at UMMC in January. Her LAD was not fixable with a stent, and she had other arteries with blockages. "They said I was a prime candidate for [the hybrid procedure], and I wasn't going to hesitate," she said.

Her operation took about five hours, while the surgeon bypassed her LAD and the cardiologist snaked in three stents. She left the hospital two days later. "I'm good now," she said, adding that she can go for walks with her husband and does step exercise with television fitness programs.

Most patients who qualify for the procedure have a blockage in the LAD that requires bypass, Poston said, and other arteries with blockages that angioplasty can open efficiently.

At other hospitals, some patients receiving conventional care get bypass and angioplasty in separate procedures days or weeks apart.

But proponents of the simultaneous procedure believe that the patient's one-time visit to the operating room is more cost-effective.

Because this procedure is so new, there is little information comparing the cost of hybrid and conventional approaches.

Walker's health insurance picked up the $80,000 charge for her procedure. A Medicare spokesman said the agency covers both bypass surgery and angioplasty. The only difference with the hybrid approach, he said, is that there is one less fee for the operating room. Officials at Vanderbilt University Medical Center in Nashville, which also performs the simultaneous hybrid procedure, said their Medicare patients have had no problems having the procedure covered.

Although the benefits of the hybrid procedure have yet to be proven in extensive studies, skeptics are not worried about compromising patients' safety.

"My perspective is that there's nothing new to it and there's nothing wrong with it," said Seides. "It's just a different way of working out the logistics of a complicated set of situations."

UMMC surgeons perform the operation "off-pump," meaning the patient's heart is beating during the surgery. This technique is said to minimize trauma and recovery time compared to traditional methods.

At Vanderbilt, surgeons stop the patient's heart and use a heart-lung machine to sustain bodily function during the operation. But the medical center is moving toward the beating-heart surgery, said John Byrne, chairman of the department of cardiac surgery at Vanderbilt.

For the near future the procedure will be limited to hospitals that build a multimillion-dollar suite housing both surgical and catheterization equipment.

The hybrid procedure may suggest that "the whole field of cardiology and cardiovascular surgery is merging," said David Zimrin, director of UMMC's cardiac catheterization laboratory. "Everything is moving toward minimally invasive" procedures, he said. "There is an emerging field called vascular medicine, in which all subspecialties will merge together." ยท

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