Y
ou’ll just have to live with it.” That’s what doctors told Donna Colicchio about her recurring attacks of atrial fibrillation. But after 20 years, Colicchio felt the scope of her existence shrinking. Once, when taking her niece to a movie, she dropped to her knees outside the theater and couldn’t get up. Another time, she brought a table set for Christmas dinner crashing down when she collapsed in her Groton, Mass., home. She had an attack on a transatlantic flight and on a beach in Barbados.
Colicchio was what physicians refer to as a “lone fibber,” an otherwise healthy person with episodic atrial fibrillation, the most common kind of heart arrhythmia, a condition characterized by irregular heartbeats. More than 2 million Americans have AF, and many, like Colicchio, have no other heart condition, though they all have an elevated risk of stroke.
In fact, by the early 1990s, Colicchio could have been cured in one fell swoop. All she needed was to have someone saw through her breastbone, pry apart her ribs, put her on a heart-lung pump, stop her heart from beating, cut a maze of incisions through her heart’s atrial chambers and sew her back up.
But Colicchio, like most lone fibbers, wasn’t considered sick enough to justify the risks of open-heart surgery. Most people with AF either aren’t treated at all or are cared for with drugs alone, even though medication relieves symptoms only half the time and may cause serious side effects. Drugs didn’t help Colicchio, but finally in 2003, with the attacks continuing, her doctor told her there was another alternative. She underwent a new catheter-based, or percutaneous (through the skin, implying a puncture rather than an incision), procedure that, like angioplasty, approaches the heart via a peripheral blood vessel. Though she required a follow-up treatment, necessary in about half the cases, she has been symptom-free ever since.
Such technological advances are helping a growing number of heart patients—from those who want to avoid or are unwilling to undergo surgery, like Colicchio, to others who are too sick or elderly to withstand the trauma of an open operation. The progress is good news for many patients, but what does it say about the future of traditional heart surgeons?
Already, surgeons have lost a third of potential patients for coronary bypass, the mainstay of cardiac surgery, to nonsurgical techniques involving angioplasty and drug-eluting stents. (That parallels developments in other specialties, in which open surgical operations for, say, removing a gall bladder, have given way to much less invasive video-guided endoscopic procedures.) Patients benefit from lower risks, less pain and horter hospital stays and recovery times. But many of the new procedures for AF and valve disease may be performed not by surgeons, but by interventional cardiologists and electrophysiologists, who are cardiologists specializing in arrhythmias.
The trend toward nonsurgical interventions (coupled with a profound decrease in reimbursement) has dulled the luster of cardiac surgery as a profession. As recently as 1990, hospitals could choose from among the crème de la crème of medical students to fill their cardiac surgery residencies. But in 2006 there were just 100 applicants for the 139 cardiothoracic surgical residency positions in the United States, and 28 of those applying were graduates of foreign medical schools. Some policy experts wonder whether even those numbers might be too high. But others worry that we could soon find ourselves with a critical shortage of heart surgeons to treat an aging population.
In 1987, when James L. Cox, a cardiac surgeon at the Washington University School of Medicine in St. Louis, pioneered the open-heart procedure that could have cured Colicchio, this much was known about the underlying physiology of AF. Normally, when the heart beats, an electrical signal known as a P wave arises from specialized muscle tissue in the heart’s atrial chamber and spreads out through a specialized conduction system, causing the heart muscle to contract. The heart then rests, waiting to be recharged for another cycle. With AF, an errant current commandeers the heart during that recharge period, causing a premature contraction and an irregular, less effective heartbeat.
Using computerized electrophysiology, which involves placing electrodes on the heart muscle, Cox mapped the cardiac rhythms of AF patients undergoing surgery for other disorders and discovered an order to the erratic rhythms. He was then able to design a pattern of crisscrossing incisions to create scar tissue that would interrupt those currents, a procedure that became known as the Cox-Maze. (Later, Cox and others found ways to accomplish the same goal without cutting the heart, using extreme cold, or cryosurgery; radiofrequency energy; microwaves; lasers; and, most recently, focused ultrasound to selectively destroy the tissue—all methods called ablation.)
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