Heart Procedure Practice at Long Beach VA Held Risky

Cardiologists at the Long Beach Veterans Administration hospital performed delicate coronary angioplasties on more than 70 heart patients in the last year although the hospital had no heart surgeons on its staff to treat life-threatening complications, The Times has learned.

The ongoing practice places heart patients in unnecessary danger, according to a recent national task force report on angioplasty. One angioplasty expert said the practices at the Long Beach VA were “against the standards of every community in the United States.”

Angioplasty is an increasingly utilized alternative to coronary artery bypass surgery. It is performed by cardiologists, who are trained in internal medicine, not in surgery. During an angioplasty, clogged heart arteries are opened with a balloon-tipped hollow tube inserted through the skin and threaded through a groin vein to the heart. About 200,000 angioplasties and 200,000 bypass surgeries were performed in the United States last year.

Dr. Victor Froelicher, chief of cardiology at the Long Beach VA, and Dr. Arthur Graham, a spokesman for the VA’s headquarters in Washington, defended the safety of the ongoing angioplasty program and said there have been no significant complications. In separate interviews, both said an arrangement for helicopter transport of surgical emergencies to Memorial Medical Center of Long Beach--about 5 miles away--provides adequate backup.

“We have no plans to discontinue (the program),” Graham said. Froelicher said: “It is in the best interests of the veterans to continue this program.”

But Friday, after inquiries from The Times, VA spokeswoman Donna St. John in Washington said a team of VA and outside experts will conduct an “on-site review” of the Long Beach angioplasty program “within the next few weeks.”

Earlier this month, a joint American College of Cardiology/American Heart Assn. task force recommended that all hospitals offering angioplasty have an “experienced” heart surgery team available “within the institution” to perform emergency surgery.

Their comprehensive angioplasty guidelines emphasize that “there should be no exception to this requirement. . . . All arrangements requiring the transportation of patients to off-site surgical facilities for such emergency surgery fail to meet the necessary standards of care exercised by prudent physicians and cannot be condoned.”

The Long Beach VA also appears to violate another of the task forces’s recommendations: “The equipment and services required to perform repeat . . . angioplasty need to be available 24 hours a day.” This is because potentially lethal angioplasty complications can develop suddenly, even hours after the procedure has been completed, according to the report.

Open Hours Limited

The Long Beach VA’s heart catheterization laboratory, where the angioplasties are performed, is open between about 7:30 a.m. and 4:30 p.m. Mondays through Fridays. During the last year, the laboratory has not been used outside of these daytime hours, according to Froelicher.

“The support people are not on call, but in an emergency we could find enough to man the cath lab,” Froelicher said. He acknowledged, however, that the hospital has no formal mechanism to swiftly mobilize the lab at night or over the weekend.

When asked about the task force report, Froelicher said that he “read it over and over again” and was “very tortured about what to exactly do with this.” He said that full discussion of the Long Beach VA’s angioplasty practices is “a good point” and that the matter “should be out in the open.”

Dr. Stephen N. Oesterle, director of the cardiac catheterization laboratory at the Hospital of the Good Samaritan in Los Angeles, said the practices at the Long Beach VA are “against the standards of every community in the United States.”

He added: “To do (surgical) standby by helicopter is ridiculous. . . . Some (angioplasty) emergencies which you encounter need to be fixed within 20 to 30 minutes. The patients are not stable for transport. They are barely able to get to the operating room next door.”

Dr. Daniel Wohlgelernter, an angioplasty expert at Daniel Freeman Memorial Hospital in Inglewood, voiced similar concerns.

Another Doctor Comments

Dr. Myrvin Ellestad, medical director of Memorial Medical Center’s Heart Institute, said: “If you are going to do high-quality cardiology, you have to have a cath lab that goes night and day.”

Life-threatening angioplasty complications, such as rupture or sudden obstruction of a heart artery, occur in a small percentage--perhaps 2% to 5%--of cases even when the cases are done by highly skilled physicians. Without quick treatment, usually immediate bypass surgery, such patients usually have severe heart attacks or die. While low-risk and high-risk angioplasty patients can sometimes be identified, it is often impossible to predict which patients are most likely to develop complications.

Oesterle and Dr. Thomas J. Ryan of Boston University, chairman of the ACC/AHA task force, said it is far safer to transfer acutely ill heart patients to a fully equipped hospital prior to the procedure rather than after problems develop, a view that was disputed by VA headquarters physicians, according to St. John.

“The fact that (angioplasty) can be done” with surgery backup elsewhere does not mean “it should be done that way,” Ryan said in a telephone interview. “We tried to state it pretty unequivocally in the language we used.”

Heart Surgery Unit Closed

Despite vigorous protests from Long Beach VA officials, VA headquarters in Washington closed the hospital’s heart surgery unit in June, 1987, after an internal audit of excessive deaths related to heart surgeries at VA hospitals across the country. For a few months, angioplasties stopped as well.

But last fall, the cardiologists were given special permission to resume the procedures. Since October, 1987, at least one angioplasty has been done a week, Froelicher said.

“When surgery was cut down here, it undermined our cardiology service,” Froelicher said. “We appealed. . . . It is hard to keep really good (cardiologists who perform angioplasty) in an academic or VA setting because they can go out (to private practice) and make enormous sums of money, like four or five times what they make here.”

The current arrangements are “a bit avant-garde,” Froelicher said. “We have immediate surgical backup at Memorial. . . . We have had (73 cases since October) without a complication with a very very good success rate. . . . We tried to choose only certain cases, lower-risk patients, ones that we feel confident we can do without complications.”

But others have felt that these arrangements may have endangered patients.

Patient Transferred

In one case early this year, the father-in-law of an employee of St. John’s Hospital and Health Center in Santa Monica was scheduled for an angioplasty at the Long Beach VA. When the medical director of the St. John’s Heart Institute, Dr. J. Michael Criley, learned that surgical backup was not available at the hospital, he was aghast. He arranged to have the patient transferred to St. John’s, where the procedure was performed successfully.

“The more I heard the less I liked it,” said Criley, who is also a professor of medicine at Harbor-UCLA Medical Center. “This is a situation I would not like to have my father-in-law in. . . . We don’t do angioplasties (at St. John’s) unless the surgeon is there and the operating room is open.”

According to Froelicher, one VA patient has required emergency helicopter transfer to Memorial, where he underwent heart bypass surgery and did well. The transfer took 23 minutes “door-to-door,” he said.

Froelicher, who is also a professor of medicine at the UC Irvine Medical School, maintained that the care of heart patients at the Long Beach VA would suffer if angioplasty were to be discontinued because it is difficult to transfer patients to the San Diego VA or West Los Angeles VA, where angioplasty and heart surgery are available. Those hospitals “couldn’t take that increased workload from what we are told,” he said. “Anytime we try to schedule patients for surgery there, there is a real big delay.”

Another Alternative

Froelicher acknowledged that another alternative is to have the VA’s cardiologists perform the angioplasties at Memorial Medical Center, which is also a UC Irvine affiliate. He said this alternative was explored but rejected by administrators because this approach would have cost the federal government substantially more than if the angioplasties are performed at a VA facility.

“Actually, that’s what we were hoping to do,” he said. “Essentially, the VA wasn’t for that because of the expense.”

Typical hospital charges for angioplasty at Memorial are between $6,500 and $7,500 a case, according to Memorial’s Ellestad. The cardiologist also said the current VA arrangements for helicopter transfer of patients are “not optimal” but “better than doing (angioplasty cases) without a backup.” He also estimated realistic helicopter transport times to Memorial at “half an hour but probably longer,” compared to the VA estimate of about 20 minutes.

There are 41 Veterans Administration cardiac surgery units. The four in California--Palo Alto, San Diego, San Francisco and West Los Angeles--also have angioplasty programs. In addition to the Long Beach VA, VA hospitals in Iowa City, Iowa, and Birmingham, Ala., have angioplasty programs, but no heart surgery units, according to Graham. He said a key difference between the Long Beach VA and the Iowa City and Birmingham facilities is that the latter two institutions are “essentially” adjacent to university hospitals where heart surgeons are available.