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Skeptics of Unusual Surgery Undergo a Change of Heart

TIMES MEDICAL WRITER

When Dr. Randas Batista spoke at a Woodland Hills heart meeting last weekend, cardiologists clustered excitedly around him afterward, practically begging a photographer to take a picture of them with him.

But two years earlier, when the Brazilian surgeon had attempted to talk about his results at a much larger heart meeting in Boston, he had been shouted down and nearly ejected forcibly.

“They went wild,” Batista said. “They wanted to kill me.”

The source of their wrath was an unusual surgical procedure Batista had developed at his “jungle hospital” to treat people with enlarged hearts.

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Contravening the conventional wisdom of heart surgeons, who preach that healthy heart tissue should be preserved at all costs, Batista cuts out large segments of the oversized heart and “throws them to the cats,” leaving behind a smaller heart that is able to pump blood more efficiently.

Batista has performed this “heart reduction” surgery on more than 350 patients, and the results, witnesses say, have been remarkable. Invalid patients who were on death’s doorstep have returned to work and are leading normal lives that they thought were forever beyond their reach.

The dramatic turnaround from rejection to burgeoning acceptance has happened in the last year, as more than two dozen heart surgeons from the United States and Europe have trekked to Batista’s tiny hospital to learn the technique and adapt it for their own practices. Skeptical at first, they have become proponents of a procedure that has the potential for treating tens of thousands of patients whose hearts are failing.

“This is a revolutionary change in surgical thinking,” said Dr. Ara G. Tilkian, medical director of cardiology at Holy Cross Medical Center in Mission Hills.

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The technique “is going to change heart surgery in the same way that coronary artery bypass did 20 years ago,” added Dr. William J. Logue of Good Samaritan Hospital in Los Angeles, who has performed the surgery 11 times in Brazil and four here. “It’s a wonderful feeling to see patients who couldn’t walk return to a normal life.”

Proponents and critics alike, however, agree that it is still a highly experimental procedure that needs to be subjected to clinical trials before it is widely accepted.

“There is little or no documentation about his outcomes, only anecdotal data,” said Dr. Nicholas T. Kouchoukos of the Washington University School of Medicine, treasurer of the Society of Thoracic Surgeons. “It may be something worthwhile or it may be a total bust. We simply don’t have enough information yet.”

Surgeons are extremely interested in it, however, because there are so many patients who could benefit. Every year, cardiologists diagnose about 400,000 cases of heart failure in the United States, where it is the leading cause of death.

About 70,000 of those victims have enlarged hearts and are potential candidates for heart transplants, which until now has been the only way to treat the problem. But only about 2,300 actually receive a new heart each year, because there are so few donors.

Batista’s surgery could serve as an alternative to transplants for most of those patients, experts say, or perhaps as a bridge to improve the patient’s chances of survival until a new heart can be found.

The idea that an important new surgical technique could come from an unknown surgeon at the 200-bed Hospital Angelina Caron in tiny Campina Grande do Sul was unthinkable to most physicians.

A tall 49-year-old with broad shoulders and big hands, Batista is an engaging speaker who quickly won over his audience at the recent talk--despite the rejections he has received in the past.

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Batista is a self-proclaimed heart junkie. “From the time I was a little boy, I’ve always dissected every heart I could get my hands on,” he said in a recent interview.

It was natural then that he became a heart surgeon. He graduated from medical school in Curitiba, Brazil, and spent 12 years in the United States, Canada and Europe in surgical training before returning to Campina Grande do Sul, a suburban village about 15 miles outside Curitiba.

His epiphany came one day when he saw a solitary water buffalo lying on its back in the forest. “That was unusual,” he said, “because water buffaloes are never alone and they don’t lie on their backs.

Approaching it, he noticed half of a coral snake sticking out from under the larger animal. “Obviously, it had bitten and killed the water buffalo, but had run the wrong way before the buffalo toppled on it.”

Dissecting both hearts, he found that, except for size, they were identical. “If you blow up a picture of the snake heart and place it beside one of the buffalo heart, you can’t tell the difference,” he said.

Further research indicated that this is true throughout the animal kingdom. No matter what size an animal is, the ratio of its heart’s mass to its volume remains constant. That means a bigger heart requires much more muscle to pump blood effectively. If the radius of a heart doubles, eight times as much muscle is required to pump blood effectively.

But when hearts become enlarged, whether it is from Chagas’ disease, a parasitic disease common in South America, or congestive heart disease, they deviate from that universal constant. They get dramatically bigger, but the amount of muscle doesn’t increase proportionately.

As a result, the organs can’t pump blood efficiently. Blood accumulates in the lungs, impairing breathing. It collects in the feet, leaving them oversized, black and cold. The blood doesn’t pump through the kidneys, so wastes aren’t cleansed.

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Most victims are confined to their beds, unable to participate in normal activities. Half die within six months.

Because he treats many patients who have Chagas’ disease, Batista desperately needed a way to make diseased hearts work more efficiently. Experimenting with goats, he found that he could remove a triangular wedge from the wall of the left ventricle to make it smaller and thereby increase the force with which it expelled blood.

“I’m not God; I can’t give it more muscle. But I can make it smaller,” Batista said.

The operation, which takes as little as an hour, is performed without stopping the heart. Blood that leaks out during the surgery is siphoned off, cleaned and reinfused into the patient.

In a typical example of the procedure shown on video at the Warner Center meeting, Batista removed nearly a pound of heart tissue, the equivalent of a normal heart, from a heart that had grown to nearly 2 1/2 pounds in size. Sewn back together, the heart resumed pumping vigorously; the patient breathed easier and his feet rapidly became pink and healthy.

Most patients resume walking in as little as two days after the surgery.

From 1984 to 1995, Batista operated on 304 patients ranging in age from 8 months to 76 years. There were 32 deaths in surgery or in the hospital during this period, and perhaps as many in the six months following the surgery. But Batista said this is an extremely high-risk population that included mostly terminal patients.

“These people are already under a death sentence,” he said. “Half will be dead within six months, and all of them are confined to their beds with no way to help their families. This is their only hope.”

He said he doesn’t know how many died later because he doesn’t have the staff and there are no public health workers to monitor the patients after they return to their distant homes. Because most of his patients have received the procedure only during the last two years, there are few long-term survivors yet. But his first patient, a young girl who underwent the surgery in 1984, still survives.

Among the survivors, the repaired hearts are, on average, pumping three or four times as much blood through the body as they did before the surgery. Most have experienced major improvements in quality of life, and many have returned to work.

Most American surgeons believe the death rate could be much lower in this country, where the personnel and equipment are superior. “I know we should be able to do much better,” Logue said.

Batista’s first attempts to speak about his work and publish his results were met with rejection and derision because they flouted conventional wisdom. Journals sent his papers back. Meeting organizers would not even let him present posters. He has recently published some results, but only in obscure journals.

Frustrated, he prepared a short video on lung reduction surgery and tacked his heart research to the end. He played the tape while commenting on a paper at a session on lung volume reduction, eliciting a thoroughly negative response.

Now that other surgeons have visited his operating room and learned the procedure, however, there is growing excitement about the procedure.

Logue, who speaks Spanish, overheard two other South American physicians at a heart meeting discussing the technique and went to Campina Grande to see for himself.

He has since performed the surgery twice with Dr. Pablo Subiate at Holy Cross Medical Center and twice, on an emergency basis, at Good Samaritan. Surgical procedures, unlike new drugs, do not require approval from the Food and Drug Administration, so Logue and others need only to receive approval from their institutional review committees, who monitor human experiments.

One of their first patients was 62-year-old Theodore Sandoval of San Fernando, who had been told by his cardiologist that he had only a week to live when he underwent the surgery Feb. 15. Sandoval had been forced to retire from his job as a driver for an auto parts company early this year because of congestive heart failure. He was continually short of breath, had dizzy spells, and his weight had dropped from 145 to 104.

Today, he is “functioning well,” according to his wife, Darvi, and his weight, now 112, is climbing. “There are days when I feel much better than I did before the surgery and days when I don’t,” he said.

Batista also described the surgery to Dr. Tomas A. Salerno of Buffalo General Hospital in New York, who agreed to visit his hospital during a planned trip to Brazil. He was greatly impressed.

“It’s an incredible idea, and it is so simple that someone should have thought of it before,” Salerno said. “Of course, in hindsight, most good ideas are simple.”

Salerno and his colleagues have performed the surgery on 12 terminal patients at Buffalo this year. Seven of them are still alive and five have improved significantly.

The operation has also been performed at Yale University Medical Center, the Cleveland Clinic and several sites in Europe.

One of the success stories is James Absalom, 65, a retired grocery store manager from Youngstown, Ohio. Absalom was bedridden awaiting a heart transplant, when surgeons at the Cleveland Clinic suggested the radical procedure. He was able to go home 10 days after the May 23 operation.

“I’m feeling great. I really am,” Absalom said recently. “I’m looking forward to getting out and doing things that I haven’t done for years,” such as bowling and attending his grandchildren’s baseball games.

“The first question most doctors have is how much to take out,” Batista said. That has to be learned by experience, but the idea is to take out as much as possible to restore the heart to near its normal size.

“Several Brazilian surgeons who tried it called me to tell me that their patients weren’t recovering as well as mine,” he said. “When I examined them [the patients], it was clear that they hadn’t taken out nearly enough tissue, and I had to do the surgery over again. The patients got better.”

Critics and proponents agree that more studies of the technique are necessary, and clinical trials are being arranged in the United States and England.

“What we have here is truly, by and large, anecdotal reports” of the type that are often disproved when controlled trials are conducted, said Dr. Robert Michler of Columbia-Presbyterian Medical Center in New York. Michler is impressed enough by others’ results to consider performing the surgery himself, however.

“From my perspective, it’s still an untested idea,” said Dr. John O’Connell of the University of Mississippi Medical Center, who is a member of the American Heart Assn.'s advisory council on heart failure and transplants. “But there have been some promising early results. If this procedure pans out, there will be substantial benefit for people who need heart replacement.”

Both sides also agree that little is known about the long-term benefits and risks because most of Batista’s patients have received the surgery in the last two years. But even if the benefit proves to last no more than a year or two, that is a significant improvement, Batista said, because the patients are freed from their beds.

“Quality of life is everything,” he said.

Who are the prime candidates for the surgery? According to Logue, the best candidates are those with myocarditis, an enlarged heart caused by a bacterial or viral infection. Other conditions that would benefit include chronic mitral valve insufficiency, end-stage aortic valve insufficiency and cardiomyopathy of unknown causes.

“Eventually, it might be used to treat all types of end-stage congestive heart disease,” he said.

(BEGIN TEXT OF INFOBOX / INFOGRAPHIC)

Smaller Is Better

Surgically reducing the size of the left ventricle, the main pumping chamber, on an oversized heart lets it contract more effectively and pump more forcefully.

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How It Works

Reducing the diameter of a heart to a size more appropriate to its mass reduces tension on the walls and allows muscles to expel more blood.


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