Too Many & Too Soon?

Some U.S. physicians asked last week whether the flurry of surgical virtuosity in heart transplants might be premature. A Canadian heart surgeon said it was. The Soviet Union's health ministry forbade Russian surgeons to do such transplants. Germany's Dr. Werner Forssmann, who won a Nobel Prize for dangerously daring heart research performed on himself, said: "I consider it a crime to perform an operation in a field where fundamental research is not yet finished."

Although the heart surgeons who had performed transplants obviously did not agree, they made no secret of their concern over the ethical problems involved. Dr. Shumway describes the procedure not as an experiment but as a "clinical trial." He does not expect heart transplants ever to become routine, partly because of the problem of supply, but he looks forward to the day when they can be considered effective treatment for selected patients.

The question then arises: For which patients? A basic rule in surgery is: "Never perform a big operation if a smaller one will do." No smaller, less radical operation offered any hope for any of the first five recipients of heart transplants. They were all patients whose condition was judged to be "terminal," whose end might come any day. In those circumstances, Shumway's "clinical trial" can be ethically justified.

Scratching the Heart. What the surgical spectaculars have done, though nobody planned it that way, is to divert attention--and possibly research money--from corrective measures for heart disease in its earlier stages, and ultimately, of course, from prevention. There are already several surgical approaches designed to repair hearts after coronary occlusion but before the damage becomes near-total and irreversible, as it had in the transplant patients.

The oldest of these, pioneered 30 years ago by Cleveland Surgeon Claude S. Beck, involves opening the heart sac and scratching the heart's surface, so that in self-defense it builds up an increased blood supply. A second technique devised by Montreal's Dr. Arthur Vineberg requires ihe freeing of minor arteries in the chest and implanting these in the heart muscle.* More radical is the removal of a pie-cut wedge of damaged heart, after which the edges of healthy muscle are stitched together. There are, in addition, several methods of reaming atherosclerotic plugs from coronary arteries.

All these techniques have been successful, in varying degrees, for small numbers of patients. But until recently, a major difficulty has been for the surgeon to determine in advance where and how big the obstruction was, and so decide how to treat it. That has now been overcome by improved techniques for X-raying the heart's arteries, developed at the Cleveland Clinic by Dr. F. Mason Sones Jr. Relying on these, two of the Clinic's surgeons, Dr. Donald B. Effler and Dr. Rene Favaloro, have performed 51 operations of a new and promising type. They cut out the diseased segment of the coronary artery itself. Then they replace it with a graft. But unlike the transplant surgeons, Dr. Effler's team has no worry about rejection because it gets the graft material from one of the patient's own saphenous veins (in the thigh). Two of these patients died soon after the operation; the others are doing well, and X rays show that their coronary blood flow was instantly improved.

Since 20 million men in the U.S. are believed to have signs or symptoms of heart-artery disease, even the most dedicated surgeons admit that the ultimate solution cannot lie in their hands, even though an entirely artificial heart may be developed. One hope is that improved drugs will first control, and eventually prevent, the atherosclerotic process. The more distant ideal is for men to adopt, early in life, patterns of diet and exercise that will make surgery and even drugs unnecessary.

* Variations of the Vineberg operation are now the commonest form of adult heart surgery in the U.S. and Canada, with almost 2,000 performed annually.

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