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Surgeons debate cardiac techniques
Surgeons debate cardiac techniques
Contrary opinions on the subject of coronary bypass surgery and transplantation were given by cardiac surgery experts at the third annual cardiovascular symposium cosponsored by the North Florida Regional Medical Foundation and the North Florida Regional Hospital in Gainesville. Heart transplant pioneer Christiaan Barnard, MD, in a press conference prior to the two-day event, touched off the dispute by calling bypass surgery the "most misused procedure" in the world today. Barnard's comment that the bypass was popular among surgeons because it was safe, easy, and profitable drew rebuttals from leading advocates of bypass surgery, including Michael DeBakey, MD, Mason Sones, MD, and Rene Favaloro, MD. Dr DeBakey, head of the Baylor College of Medicine, Houston, defended the bypass procedure, pointing out that nearly 10,000 such operations had been carried out at Baylor since 1964, and that his group now does about 12 a day "with good results." The pioneer of coronary arteriography, Dr Sones of the Cleveland Clinic challenged Dr Barnard to produce data that would support the South African's criticism of bypass surgery. Dr Barnard declined. Dr Favaloro, director of heart surgery at the University of Cordova in Buenos Aires, also disputed Dr Barnard's claims and stated, "I cannot believe Dr Barnard said coronary bypass surgery was done primarily for lucrative reasons. Definite data proves the bypass improves the quality of life and prolongs life," said the first man ever to perform a successful bypass. Dr Barnard
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later agreed that if the indications were proper, he too would undergo a bypass operation. In a related argument, Dr Barnard played the role of defender rather than critic. He strongly supported the heart transplant technique, citing recent comments by other surgeons that the bypass had replaced the transplant as "the biggest lot of nonsense out." Dr DeBakey responded that he had no interest in transplantation. "We stopped doing heart transplantation after experiences with 12 patients, only 2 of whom had any long-term survival." Dr Favaloro reluctantly admitted that transplants are good for those patients who have no heart muscle left. He said he had performed two, but "until there is an answer for rejection, I will do no more." Dr Barnard advocates heterotrophic transplants-connecting a second heart to help the first-and says his patients prefer the heterotrophic technique. "They feel better knowing their own heart is there to help," he said. To date, Dr Barnard noted, 299 heart transplants have been done worldwide. "Of these, 55 patients are alive with functioning grafts." Two of Dr Barnard's nine transplant patients are still alive. Referring to those who did not survive, Dr Barnard explained, "A doctor's primary duty is to alleviate suffering, not to lengthen life. In this context, transplants are successful." One of the emotional highlights of the symposium was provided by Albert Starr, MD, developer of the prosthetic heart valve, who three years ago underwent bypass
A O R N Jorirrinl, Dereniher.1976, Vol 24, N o 6
surgery himself. He claims the experience has helped him immensely in understanding what his patients are going through. Dr Starr outlined four major lessons for physicians in dealing with their patients. “First, give the patient as much factual information as he can handle. Knowledge breeds confidence. Second, be especially compassionate with the family. A few minutes of your time saves so much anguish. Third, be sure the patient is properly medicated for pain in the postop period. Pain varies among pa-
tients, so be sure each is comfortable. Finally, help the patient with his rehabilitation. He needs help. I advocate a carefully individualized exercise program.” Dr Starr pointed out that as a patient, his principal image of the hospital came from the nurses, orderlies, and aides. “I rarely saw a doctor.” He stressed the importance of “smiling, accommodating, well-trained’’ staff to help the patient and to give a good image of the hospital.
Advantages of autotransfusion
incidence of transfusion-related lung and kidney damage, relative preservation of clotting factors, and decreased requirement for bank blood,” said Dr Stehling. Another option is to withdraw the blood from the patient immediately before the operation and replace the volume by solutions containing dextrose, salt, and protein. While the reinfusion of blood lost as a result of injury or operation has been known for 150 years, only in recent years have sophisticated techniques been developed to make it a safe and useful procedure. The blood is suctioned, treated with an anticlotting agent, and then filtered before being reinfused into the patients at the rate of 600 to 800 cc per minute. Patients for whom the procedure is particularly useful include women with ruptured tuba1 pregnancies; victims of falls, beatings, or traffic accidents resulting in injury to the liver, spleen, or other internal organs; patients who will be undergoing surgery involving large blood loss; and patients with rare blood types who otherwise might be denied surgery or would risk bleeding to death. Dr Stehling said patients for whom the procedure should not be done are those with cancer cells in the system, with infected fluid, or with bowel contents in the body cavity. Not all blood cells are retrieved in autotransfusion but those red cells obtained have a normal life span and are capable of carrying oxygen normally, said Dr Stehling. Even though this method proves effective, it will only represent a partial solution to the increasing demand for blood transfusions.
By reclaiming the patient’s own blood lost at the operating table and reinfusing it into the vein, major dollar savings have been achieved at the Bexar County Teaching Hospital of the University of Texas Health Science Center, San Antonio. Of far greater consequence, said Linda Stehling, MD, associate professor in the department of anesthesiology, is that several patients would have died due to unavailability of bank blood. Speaking at the annual meeting of the American Society of Anesthesiologists, Dr Stehling said that scavenging of blood during the operation has been carried out for the last five years. The volume of autotransfusion procedures has ranged between 20 cc and 40,000 cc of blood (average 3,302 cc). “As a conservative estimate, the economic benefit to the 180 patients who received a total of 594,000 cc of blood (1,189 units) was $59,450,” she said. There are other methods of autotransfusion. Blood may be collected from a patient over a period of days or months and stored in the blood bank for use when the patient is to undergo an elective operation in which blood loss may be large. While deeply frozen blood may be stored for several years, conventional blood banks can store it for three to four weeks. ”Advantages of any autotransfusion technique include ready availability, compatability, freedom from donor-borne diseases, such as hepatitis, decreased
1200
A O R N Journal, December 1976, Vol 24, N o 6
Contrary opinions on the subject of coronary bypass surgery and transplantation were given by cardiac surgery experts at the third annual cardiovascular symposium cosponsored by the North Florida Regional Medical Foundation and the North Florida Regional Hospital in Gainesville. Heart transplant pioneer Christiaan Barnard, MD, in a press conference prior to the two-day event, touched off the dispute by calling bypass surgery the "most misused procedure" in the world today. Barnard's comment that the bypass was popular among surgeons because it was safe, easy, and profitable drew rebuttals from leading advocates of bypass surgery, including Michael DeBakey, MD, Mason Sones, MD, and Rene Favaloro, MD. Dr DeBakey, head of the Baylor College of Medicine, Houston, defended the bypass procedure, pointing out that nearly 10,000 such operations had been carried out at Baylor since 1964, and that his group now does about 12 a day "with good results." The pioneer of coronary arteriography, Dr Sones of the Cleveland Clinic challenged Dr Barnard to produce data that would support the South African's criticism of bypass surgery. Dr Barnard declined. Dr Favaloro, director of heart surgery at the University of Cordova in Buenos Aires, also disputed Dr Barnard's claims and stated, "I cannot believe Dr Barnard said coronary bypass surgery was done primarily for lucrative reasons. Definite data proves the bypass improves the quality of life and prolongs life," said the first man ever to perform a successful bypass. Dr Barnard
1198
later agreed that if the indications were proper, he too would undergo a bypass operation. In a related argument, Dr Barnard played the role of defender rather than critic. He strongly supported the heart transplant technique, citing recent comments by other surgeons that the bypass had replaced the transplant as "the biggest lot of nonsense out." Dr DeBakey responded that he had no interest in transplantation. "We stopped doing heart transplantation after experiences with 12 patients, only 2 of whom had any long-term survival." Dr Favaloro reluctantly admitted that transplants are good for those patients who have no heart muscle left. He said he had performed two, but "until there is an answer for rejection, I will do no more." Dr Barnard advocates heterotrophic transplants-connecting a second heart to help the first-and says his patients prefer the heterotrophic technique. "They feel better knowing their own heart is there to help," he said. To date, Dr Barnard noted, 299 heart transplants have been done worldwide. "Of these, 55 patients are alive with functioning grafts." Two of Dr Barnard's nine transplant patients are still alive. Referring to those who did not survive, Dr Barnard explained, "A doctor's primary duty is to alleviate suffering, not to lengthen life. In this context, transplants are successful." One of the emotional highlights of the symposium was provided by Albert Starr, MD, developer of the prosthetic heart valve, who three years ago underwent bypass
A O R N Jorirrinl, Dereniher.1976, Vol 24, N o 6
surgery himself. He claims the experience has helped him immensely in understanding what his patients are going through. Dr Starr outlined four major lessons for physicians in dealing with their patients. “First, give the patient as much factual information as he can handle. Knowledge breeds confidence. Second, be especially compassionate with the family. A few minutes of your time saves so much anguish. Third, be sure the patient is properly medicated for pain in the postop period. Pain varies among pa-
tients, so be sure each is comfortable. Finally, help the patient with his rehabilitation. He needs help. I advocate a carefully individualized exercise program.” Dr Starr pointed out that as a patient, his principal image of the hospital came from the nurses, orderlies, and aides. “I rarely saw a doctor.” He stressed the importance of “smiling, accommodating, well-trained’’ staff to help the patient and to give a good image of the hospital.
Advantages of autotransfusion
incidence of transfusion-related lung and kidney damage, relative preservation of clotting factors, and decreased requirement for bank blood,” said Dr Stehling. Another option is to withdraw the blood from the patient immediately before the operation and replace the volume by solutions containing dextrose, salt, and protein. While the reinfusion of blood lost as a result of injury or operation has been known for 150 years, only in recent years have sophisticated techniques been developed to make it a safe and useful procedure. The blood is suctioned, treated with an anticlotting agent, and then filtered before being reinfused into the patients at the rate of 600 to 800 cc per minute. Patients for whom the procedure is particularly useful include women with ruptured tuba1 pregnancies; victims of falls, beatings, or traffic accidents resulting in injury to the liver, spleen, or other internal organs; patients who will be undergoing surgery involving large blood loss; and patients with rare blood types who otherwise might be denied surgery or would risk bleeding to death. Dr Stehling said patients for whom the procedure should not be done are those with cancer cells in the system, with infected fluid, or with bowel contents in the body cavity. Not all blood cells are retrieved in autotransfusion but those red cells obtained have a normal life span and are capable of carrying oxygen normally, said Dr Stehling. Even though this method proves effective, it will only represent a partial solution to the increasing demand for blood transfusions.
By reclaiming the patient’s own blood lost at the operating table and reinfusing it into the vein, major dollar savings have been achieved at the Bexar County Teaching Hospital of the University of Texas Health Science Center, San Antonio. Of far greater consequence, said Linda Stehling, MD, associate professor in the department of anesthesiology, is that several patients would have died due to unavailability of bank blood. Speaking at the annual meeting of the American Society of Anesthesiologists, Dr Stehling said that scavenging of blood during the operation has been carried out for the last five years. The volume of autotransfusion procedures has ranged between 20 cc and 40,000 cc of blood (average 3,302 cc). “As a conservative estimate, the economic benefit to the 180 patients who received a total of 594,000 cc of blood (1,189 units) was $59,450,” she said. There are other methods of autotransfusion. Blood may be collected from a patient over a period of days or months and stored in the blood bank for use when the patient is to undergo an elective operation in which blood loss may be large. While deeply frozen blood may be stored for several years, conventional blood banks can store it for three to four weeks. ”Advantages of any autotransfusion technique include ready availability, compatability, freedom from donor-borne diseases, such as hepatitis, decreased
1200
A O R N Journal, December 1976, Vol 24, N o 6