New Freeways for the Heart

As many as 70,000 coronary bypass operations are now being performed in the U.S. each year at total costs ranging from $8,500 to $25,000 apiece. Some doctors criticize this boom; the National Heart, Lung and Blood Institute has released results of a four-year study of 288 heart patients, suggesting that medicinal treatment may often be as effective as surgery. But there is no doubt that the operations can reduce angina--the severe chest pains suffered by some heart patients with clogged arteries. In addition, doctors are reporting new evidence that the operations prolong and improve the lives of many other patients with serious coronary disease.

In these operations, the functions of damaged arteries are taken over by sections of the patient's own veins, which are grafted onto the heart to restore the flow of blood past arterial blockage. Success depends heavily on the surgeon's skill. Of the many bypass teams at work, few if any can match the record of the groups at Honolulu's Queen's and Straub hospitals. One of several heart surgeons operating there, Dr. Richard Mamiya, 52, a mainland-trained, third-generation Japanese Hawaiian, has performed 350 consecutive operations without a single fatality, at times installing as many as eight or nine grafts.

TIME Contributor Gilbert Cant "scrubbed" with Mamiya and watched him and his multiracial team perform a typically delicate coronary bypass operation. His report:

It was 8:45 a.m. when I accompanied Mamiya into his compact operating room. Suited up in antiseptic green, he slipped on bugeye magnifying spectacles. His assistants had, already been at work for 30 minutes. The chest of the patient, a man of 61, had been cut open from the collarbone down through the breastbone. Metal clamps held the chest wall open to reveal the heart. Near by on the operating table were two foot-long pieces of saphenous vein, a superficial vein that had been "harvested" from the patient's left thigh and leg.

As Mamiya quietly took his place at the patient's right side, the nine other team members shifted to their own stations around the operating table. While Mamiya examined the patient's exposed heart and arteries, assistants read off his temperature (lowered to 30DEG C., 86DEG F.), heartbeat and other indexes. All were satisfactory. With a murmured command from Mamiya, the patient was placed "on the pump"--the heart-lung machine that would perform critical circulatory and respiratory functions for him while Mamiya worked on the exposed heart.

The patient had a severe complication: the lower part of his left ventricle --the heart's main pumping chamber--had ballooned into an aneurysm, a pocket of scarred, essentially dead tissue. After sewing a piece of protective tape around the aneurysm's base, Mamiya sliced away the diseased, inert clump and closed the three-inch wound with a thread so thin that it was scarcely visible.

Mamiya knew beforehand where the vital coronary arteries were seriously blocked, but he took one final look at the X rays and compared them with what he saw in front of him. Then he proceeded. Taking one piece of vein from the leg, he grafted it to three points on the heart's surface, thus making sequential or "leapfrog" bypasses around two blocked sections of the arteries in a single maneuver. With another piece of the same vein, he made a third bypass.

"How long on the pump?" Mamiya asked.

"One hour 38 minutes."

"All right," he said. "Off!"

Fed by its new arterial supply, the patient's heart might have sprung back into action spontaneously. Instead, it twitched uselessly. Mamiya coolly called for the paddles--two plastic-covered electric stimulators--and pressed them against the exposed heart. It jumped under the shock, but continued twitching ineffectually.

"What power are you on?" Mamiya asked.

"Twenty."

"Go to 30."

Still no beat.

"Make it 40," Mamiya said. The heart leaped, then settled into a natural rhythm of about 70 beats per minute.

As blood coursed through the new "arteries," Mamiya checked the connections for tightness and started the final phase of his task. Because the remaining vein segments from the left leg were too narrow, he ordered the right leg opened and its saphenous vein removed. Taking two pieces of this vein, which proved to be of heavier caliber, he anchored them to the aorta; then he attached one to the posterior descending coronary artery, the other to the left anterior descending artery. In effect, he had used the first three bypasses to clear traffic through the clogged local streets--and the aortic bypasses to provide two expressways for additional free flow.

Satisfied with his deft work, he turned over the job of closing up the patient to other members of his team--doctors who were preparing to become chief surgeons themselves. Mamiya had spent two hours at the table.

Seven Bypasses. Mamiya is modest about his achievements, but others are vocal. One articulate testimonial to the surgeon's skill is Buck Buchwach, the Honolulu Advertiser's executive editor, whose case has drawn much attention to the advanced state of surgery in Hawaii. "Bucky" had had two heart attacks, the first at age 37, and a two-bypass graft at a famous U.S. mainland center. Results were unsatisfactory. Barely surviving a third attack a year ago, he was referred to Mamiya, who put in seven bypasses. At 56, Buchwach now works with "front page" drive and even feels good enough to play touch football with his youngsters.

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