Overnight recovery possible with new bypass procedures.

Heart bypass surgery was performed in Little Rock in the spring of 1997 on a man in his mid-50s.

What made this procedure unique is that, according to Dr. Michael Bauer, the surgeon who performed the operation, the patient theoretically could have been up and out of the hospital the next day.

He remained hospitalized a little longer for precautionary reasons. But his story is far better than most heart-bypass patients, who typically spend a week or more in the hospital recuperating, plus many more weeks at home where they are slow to get back to speed.

The reason this heart bypass required little recuperative time is because it was performed through a minimally invasive procedure - the newest wave to hit the cardiac market in Arkansas.

Routine open-heart surgery requires the sternum, or breastbone, to be split apart, a large incision made in the chest and the rib cage pulled away. Patients experience a great deal of pain for some time after surgery.

The minimally invasive surgery procedures cropping up in Little Rock allow for heart surgery without the chest being opened to such extreme. Patients experience far less pain - some report only minimal discomfort; they are back on their feet in a matter of hours; their hospital stay is drastically reduced; risk of infection is lowered; and the overall costs are far less, Bauer says.

Nationally, the average for open-heart surgery runs $25,000. Insurers tend to like and will cover the minimally invasive surgery.

But this isn't to say that open-heart surgery will immediately shift to minimally invasive procedures.

"It's not going to be a panacea for everybody," says Bauer, who performed the aforementioned heart bypass at St. Vincent Infirmary Medical Center.

"Most patients are going to require the standard, cut-down-the-middle operation," he adds. "But it's hot. Nobody wants to have their chest cracked open."

Katie Ferguson had a picture of horror at the thought of her chest being cut open for heart surgery. The 65-year-old Ferguson needed a bypass. An angioplasty (a balloon routed through the artery to break up the plaque) was ruled out as being too risky by her physician, Dr. Andrew Kumpuris, she says, and open-heart surgery was deemed too stressful for her age and condition. Minimally invasive surgery was the only option, she says.

"I was so elated when they told me about this new deal," Ferguson says. "I wanted it. I felt like I didn't have anything to lose."

Two days after surgery, Ferguson was sitting in a chair in her St. Vincent hospital room, eager to go home.

"I feel great," she says. I'm just a little sore, but I can get around fine."

Ferguson was eager to get back to her garden and big yard at home.

"I can breathe so much better now. I turned 65 and fell apart. I had never been sick. I had been healthy all my life. I can't believe this [surgery], I really can't. When the technician walked me down the hall yesterday, I couldn't believe it. So far, so good."

The operation Bauer used on Ferguson is called a minimally invasive direct coronary artery bypass (MID-CAB). It falls under the popular term keyhole because the incision is relatively small (about three inches). The horizontal cut is made between the fourth and fifth ribs on the left side of the patient, near the sternum, giving the surgeon direct access to the lower area of the heart and the left anterior descending coronary artery, where many single bypasses are needed.

Bauer also uses a keyhole technique called the Cosgrove method, named for innovative Cleveland physician Tobey Cosgrove, who developed the procedure. This cut is on the right side of the sternum, a little higher than the MID-CAB, giving access to the valves of the heart and allowing for repair of heart defects or a bypass of the right coronary artery. This surgery requires a vertical cut and separation of a couple of ribs from the sternum.

Another method that arrived in Little Rock with great fanfare in March 1997 was the port-access method. Dr. Bill Fiser, a cardiovascular surgeon at Baptist Medical Center, performed the first port-access surgery. This requires small incisions, or ports, on the left side of the chest through the ribs.

Each procedure has its pluses and minuses.

With port access the surgeon can perform a multiple bypass; the MID-CAB is used mainly for a patient needing a single bypass of anterior coronary arteries.

The MID-CAB surgery can be performed without the heart being stopped. When a heart defect is repaired through the Cosgrove method of keyhole surgery, or if the port-access method is used, the heart must be stopped and the patient placed on a heart-lung machine. It's estimated that this adds $5,000 to the cost of the operation.

With the MID-CAB and Cosgrove, the surgeon has a direct view of the heart; port-access is done endoscopically.

Each of the methods makes heart surgery more difficult for the physician but far better for the patient, Bauer says.

New Technique Arrives

Bauer first learned of the Cosgrove method during a teleconference in Dallas during the fall of 1996. Lisa Smalley, a 37-year-old El Dorado resident who had an arterial septal defect - a hole in the heart was the first patient to undergo the minimally invasive procedure on Oct. 1, 1996.

Smalley's husband had undergone major bypass surgery the old-fashioned way several months earlier. Smalley says Bauer was shocked when she quickly agreed to the new technique.

"I didn't even blink an eye," Smalley says. "He said he was 100 percent sure he could do it, and asked if I would like to try it. He did my husband's surgery in February [1996]. I trust him and I knew he could do it. He's the best."

Smalley says a month after surgery she had resumed shopping, driving and house cleaning. She also says the surgery scar is completely gone.

Kathie Osborne, who is vice president for development of the Arthritis Foundation in Little Rock, also was a patient for keyhole surgery with a congenital ASD.

"I was absolutely terrified about open-heart surgery," Osborne says. "Dr. Bauer kept telling me about this new surgery and said it was up to me if I wanted it."

Osborne says she remembers very little of the first two days after surgery, but that she recalls very little pain. "When he

came in and took the tubes out, it didn't even hurt. I never had any pain from the incision . . . As soon as I woke up, I could walk.

"It's amazing. I'm just glad he had learned this procedure."

Bauer learned the MID-CAB surgery at a video conference in Oregon. The two operations he performed last week were his fourth and fifth with that procedure.

An Arkansas Business reporter was allowed to view one of the procedure. Much of the surgery involved Bauer easing the left internal mammary artery from the chest wall and using it for the graph on the blocked coronary artery.

"This graph is better, it lasts much longer than a vein graph," Bauer says.

A mistake in separating the graph artery and the operation is a wash. "You have to walk your way in slow and easy," Bauer says during the procedure. "This is the tedious part of it."

Operating on a beating heart, Bauer must use a stabilizer attached to the retractor to keep the coronary artery in place. Carbon dioxide keeps the area clear as the graph is sewn onto the coronary artery. "I can see this as well as if the heart were completely stopped," the surgeon says.

A chest tube is inserted to drain blood, and it will be removed the next day. The patient will be give a pain killer and will awaken in a few hours. After two hours and 10 minutes, the procedure is finished.

Baptist Breakthrough

The port-access technique was first performed by Fiser in March.

Dr. Greg Fontana of Cedars-Sinai Medical Center in Los Angeles said in an issue of Newsweek recently that the new technique was the biggest advance in heart surgery in 20 years. The port-access technique is used in single and multiple coronary bypass surgery and mitral valve replacement.

Fiser says Baptist is among "the very first large, private medical centers in the nation to receive training" for the port-access technique. Heartport, the company which developed the procedure, "targeted us because of the excellent results of our cardiac program."

With port-access, the heart-lung machine is attached to an artery and vein through a small incision in the leg. For bypass surgery, surgeons take a replacement artery from another part of the body and sew it on the coronary artery below the blockage, restoring blood flow to the heart.

Dr. John Hearnsberger, another Baptist Heart Center surgeon, says, "Port-access combines the advantages of a minimally invasive approach with the best of conventional heart surgery standards."

Fiser says that after port-access, "patients should be able to return to work within two to three weeks, rather than the two to three months required for standard bypass."

Cardiac work makes up a large percentage of Little Rock hospitals' income. And with the arrival of the Arkansas Heart Hospital, competition between the existing providers escalated. Baptist unveiled a media blitz when it debuted the port-access surgery.

"There is competition between the hospitals, and the perception is that there might be competition between doctors, but that's not the case," says Bauer, who points out that Fiser and most of the cardiovascular surgeons in Little Rock work at each of the hospitals offering heart surgery.

Insurance and managed care is pushing the surgeons to work throughout the city. And, says Bauer, economics is driving the move to the new, less invasive procedures.

"It's all frontier stuff. It will evolve over the next two-three years. But the best thing about it is, it's better overall for the patients," he says.