The Operation; Part 2

<v Man 1>Graft w-w- inflate it with the saline solution. We're trimming the vein to the proper length. And then we'll sew the vein on to the aorta. <v Man 2>A question for either Dr. Dietrich or Dr. Kinard. Uh we are using human tissue here for the bypass graft. In other words, the veins uh has it either been tried or is it practical to use artificial materials such as Teflon tubes or other synthetic materials for these grafts? <v Man 3>Other materials have been used uh and other vessels have been used. The internal mammary artery, for instance, has been used and works very well. Um other arteries have been used, but don't work quite as good as the uh saphenous vein. The saphenous vein works best uh because it is a vein in the leg and thus has all the hydrostatic pressure and thus the wall is much thicker than the other veins in the body and the u- upper extremity. Uh these artificial uh bypasses that had been used in the heart are not very successful in that they tend to clot off, whereas the saphenous vein and the internal mammary artery uh stay open anywhere from 80 to 98 percent of the time uh so that uh they approved over the period of time that we'd been doing bypass surgery, much more successful than any other uh method. <v Dr. Edward B. Diethrich>Dr. Kinard we are looking right in the aorta through these little hole and sewing the vein graft on to them and we're we're very happy in this particular case that there's not much after a process in the ?inaudible? aorta. It looks like his ?inaudible? was fairly often find through his coronary arteries. The aorta looks pretty clean. What were the major risk factors that that this patient had in terms of the reduction of coronary arterial disease?

<v Man 3>He has a family history of coronary arterial disease. He's somewhat overweight. He's fairly sedentary. His cholesterol is up- at the upper limits of normal. He probably has the stresses that we all have. He smoked in the past. His blood pressure was normal. So that was not a risk factor. Uh he did not have diabetes. So that his main risk factors uh I uh mentioned. <v Man 1>As I said at the beginning of the program, the operation doesn't cure this heart disease. Now that you have listed those risk factors and you see these three coronary bypasses being sutured in, what will be the program in terms of reduction of risk factors that will warrant for this particular patient once he leaves the hospital or even perhaps before he leaves? <v Man 3>Well, of course he's done one of the very important things, and that is he stoped smoking. But he did it just as a lot of folks do and that is only when he got a warning, namely had a heart attack, that he uh have enough sense to do it. Uh so that's taken care of. And I think the next step is going to be developing uh a program so that he loses weight. He starts on an exercise program uh and usually even while the patient's in the hospital we'll begin an exercise program, then when they go home, they'll continue this as an outpatient. Of course with dietary management uh along with the program.

<v Man 1>We're gonna be establishing Dr. ?Dyas? at the Arizona Heart Institute a dietary internship. How important do you think that nutrition and nutrition counseling is now needed during this period when we're trying to get him in a better cardiac condition? <v Man 3>Well, I think uh in the initial portion, we're trying to get him well from the operation. So I don't think it's as important then as it is, oh, down the line. Uh but I think it does have some importance down the line. I don't think diet is nearly as important as I say as the fact that he stopped smoking uh but I do think it's important.

<v Dr. Edward B. Diethrich>Now we're uh we finished the second anastomosis. And we're ready now to do the third one. I think we probably better report back up with Dr. ?Dyas? and see what's happening in our blood gases, because before long, we're going to be at a point where we wanna come off the heart lung machine and wanna be certain at that time that everything is satisfactory. ?Dyas? uh would you please give us a a little progress report? <v Speaker>OK. We look back at the screen after we defibrillatored the heart. We have a normal sinus rhythm or essentially a normal sinus rhythm, occasionally an extra beat. This line here, you can see the little blips on the screen. This is indicative of the heart opening the valve. That's the heart heart's own beat that's opening this valve and responsible for this little pressure here. <v Speaker>We're still on the car, on the bypass pump, and that's giving about ninety nine percent of the pressure that we have here now. There's no new blood gas is on the screen, so I can't give you two new reports on that.

<v Speaker>Are you satisfied, Dr. Dayas, with the way the electrocardiogram looks at this time? <v Speaker>Yes, the electrocardiogram looks very good at this time for the temperature that we're at. And the time that we since we defibrillator the heart water, what are changes that you're looking for? <v Speaker>Obviously, we talk to patients about this kind of an operation. They are anxious to know what the risks are at this particular time in the operation when we're doing these final ceilings. <v Speaker>The heart is rewarming and you're looking at it like a cardiac death, a kidney. You are learning things up there that you might look at that would give us an idea that things are either good or not so good. <v Speaker>Well, compared to the preop electrocardiogram, which was very normal looking, normal sinus, we're looking at GSD segment to see if there is any changes in TSD segment, which would indicate some a schema or something of that nature, which would might indicate that he's either had a heart attack during the operation or as being denied enough blood to that part of the muscle. We don't see that. We see some inversion of this little wave here, the T wave, which at this time didn't mean anything at all. I expect by the end of the procedure that the EKG look very similar to the pre up on the screen there. <v Speaker>Gary, we are using your bio medicus pumps this evening, aren't we? Yes. Can we demonstrate one of the values of the biomedical medicus pump in terms of being able to do pulsatile flow during the bypass? All right. Well, we demonstrated that got to do as we do on the screen. You can show that and then we'll show the pump in very controlled back.

<v Speaker>Right now, it's a nonpartisan town hall. He is opening his valves somewhat, which would make it closed. Gary is now demonstrating the tough pulsatile aspect of the bond medicus pump. <v Speaker>And you can see here the pump is responsible for these waves that you see on the screen now. <v Speaker>Essentially, what you're saying is that the pump is simulating what blood pressure would look like on that screen. A a forceful pumping of blood and a relaxation of forceful pumping of blood and a relaxation. That's correct, Rick. <v Speaker>That's important in a situation where one is, for instance, doing an operation on the heart and the patient also has disease and say the arteries to the brain so that a pulsatile flow results in a higher pressure off and on. Thus, you get more flow to the brain with the higher pressure. Whereas if you keep it at a low pressure all the time, you don't have much flow to the brain. <v Speaker>And we had a good view, are there. Gary, have you shown that to. Well, yes, most of it you can only see on the screen on the back portion back here. I have back here as a drive unit that I can set as far as rate, how fast I'd like it to come up and the duration.

<v Speaker>Will see that. Gary, while we have you on them, on the microphone there, what is the attempt to the patient? Right now we're 37 degrees, which is normal thermic. Well, that's just perfect then, because we go look overhead here. We're putting in the last suture on the last thing bypass or, you know, have come out just even in terms of the time we want to use. Now, there is some air trapped in this arson yard at this point. <v Speaker>So what we'll do is place some small bulldog clamps on these very bypass graft cases being. But that bypass right here place a bulldog on it. <v Speaker>Here goes. And now shut the fuck off for a second if we shut the top off with your arms. And we'll evacuate the air from the assignee order and take that clamp right off. OK, we then can turn the pump back on. Come on. Will secure these suture by tying the final nasch. We can see what appear to be rotating devices, propeller like devices. <v Speaker>That's the pump itself, right? I should mention that a bulldog clamp is merely a very small clamp for arteries and veins.

<v Speaker>There's a better view. You can even you can see the paddles as they as they essentially massage the plastic tubes and push the blood through the pump is the blood. So are the blood cells subjected to any damage as those of those pumps turn around? <v Speaker>Well, there is some minor damage, but the degree of damage is not that great. <v Speaker>But it is still to the advantage of the patient to keep him on the heart lung machine as short a time as possible. Correct. <v Speaker>Now, two shared to. There's no air in these fame by fast grass. We're going to just take this refind needles, very fine needle and we'll just. <v Speaker>Inserted into the vein graft. So if there's any air there that air evacuate and then we'll be able to remove it. Well, our plans once again.

<v Speaker>Adak Dias, did you get a new blood gas is back since the last time? <v Speaker>Yes. Back. Are you satisfied? Don't order and we can come off the phone by you. <v Speaker>Yes, we can come off the phone. I'd like not lift the hard data card and show you the very fast graphs. <v Speaker>The one that's easiest to see is the anterior descending. <v Speaker>You can see here is the heart. It's beating normally now. It's still empty, of course. The art above. Here's the vein bypass graft going to the arm, sitting in corner. The obstruction is at this point. We demonstrated that earlier with the dilator that you can see why we call a bypass because it detours around and then flows new blood. Beyond the obstruction, the heart muscle down here. We'll just take a quick view, looking over to see if these other Anasta mostly got fine. We can see they look very satisfactory. I think at this particular time, Geering, we can probably start to put a little blood into the heart since we're at normal temperature. All right. And allow the heart to take over some of the function itself. <v Speaker>What we've got is that this is that occurs when we look at the screen. OK, guys, if you'll demonstrate the pressure on the assembled skull now, I think that we'll be able to show this heart begins to take over, that there is a good pressure component coming from the heart itself.

<v Speaker>The heart is still empty at the present time. The pressure tracing is still small. Now, now you can see the heart is beginning to take over the function of pumping blood as the heart is filled. <v Speaker>This is the central east. Pressure is increasing. <v Speaker>Is Gary's putting more and more blood into the heart and the heart's responding by taking over more of the function of pumping blood. <v Speaker>Now, how do we know that Dad is looking at the time we're ready to come off the pump completely? <v Speaker>Can you? Yes. When the blood pressure gets up to a point where it's adequate for profusion of body and central veins, pressures in the normal range, the electrocardiogram looks OK. We'll know then that we're able to come off the bypass. <v Speaker>We're looking around at each of these and asked mostly not after kind of before we come off completely and occasionally we see a little area in between the vein and the artery and we might want to put the stitches we've just done here. So we come off. There won't be any leaking of blood around the anastomosis itself.

<v Speaker>The heart appears to have a very regular rhythm at this time. Yes, it's a little slow yet. <v Speaker>And it's a little fall how we level on our central venous pressure now. Yes. OK. <v Speaker>And what you wrong, Gary? Well, right there is about one leader per minute pirate state. <v Speaker>We'll stand by a leader and we pick this right up, Lowgar. <v Speaker>You have to make sure that those graphs are good and tight. It is essentially a matter of visual inspection for leakage of blood at this point, correct? <v Speaker>That's not necessary until one reverses the heparin and allows the patient to clot because, of course, the needle holes will not clot until you reverse the heparin. And you don't want to do that until you're off the heart lung machine.

<v Speaker>Now, you'll also be injecting a compound into the circulation system that tends to reverse the effects of a protein solution. That's correct. <v Speaker>Because the heart has been cooled and, of course, to a certain extent traumatized by not having any circulation for a period of time, it takes a little while for it to come back. So that requires assistance from the heart lung machine. <v Speaker>And what we're doing now that, Kyra, is just waiting long and hard to come back. <v Speaker>We're balancing the arterial pressure with the venous pressure and watching the oscilloscopes. So if that's even bigger than.

<v Speaker>Do you actually get your. Dietrich, as you know, one of the features of this telecast is the opportunity to speak directly to some of the members of the viewing audience. Will you be very soon able to take some of those calls? <v Speaker>Yes, Rick. And just a few moments we're going to come off the bypass here in a few moments and once more. We'll be happy to answer some questions. And meantime, you might one doctor kind of feel the feel of those questions? Well, we're kind of finalizing the operation here. <v Speaker>One of the initial questions I have a little bit about technique, we noticed that he used an arterial punch, a small device that produced very, very uniform holes in the aorta. That was not the case at the distal end. Why not? And why was it necessary to use uniform holes along the aorta? <v Speaker>Well, of course, the aorta is much thicker than the small coronary arteries. And the work which ones does on a small corner artery is very fine. Once one makes just a little incision into the coroner artery, that's adequate to connect the big vein. Usually the vein is two to three or more times larger than the coroner artery to which one's connecting it. On the other hand, the aorta is a very large vessel and a very thick vessel. And therefore, when one connects a rather flimsy vein to it, then one wants to make sure that it's not just a slit in the aorta, which may narrow, but a hole which can connect directly to the vein because the vein will not hold it open. But because the aorta so thick, whereas a vein and the coronary artery will be held open by blood vessels, a relatively thin wall.

<v Speaker>A question about cardiovascular medicine. You're a cardiologist. You you're obviously very interested in taking care of this patient after the surgery. We mentioned that the surgery is a palliative procedure. It will relieve symptoms, but it will not stop a progressive medical disease, a biochemical disease. Is it? Give me some numbers. Do some of these vein grafts close up, suffer the same sort of obstructions as the original core econo vein grafts do two things. <v Speaker>One, nature's way sort of results in the vein graft narrowing down to the same size as the artery to which you connected. And this is done by what we call andiamo proliferation. And that is division. We think of the inside wall of the vein or possibly by laying down some of the little platelets on the wall of the vein or a combination of both. This is a natural process.

<v Speaker>On the other hand, atherosclerosis hardening of the arteries is a progressive disease in the corner arteries. And it may be a progressive disease in the vein bypass as well, because, as you say, this is a palliative operation. It's not a curative operation. We don't have a cure for this for this disease. We think the risk factors help us to slow down the progress of this disease. But they don't stop the progress. <v Speaker>Essentially, you you are literally shifting the life curve, adding that life expectancy to these patients. But inevitably, you haven't stopped the progression of the disease.

<v Speaker>That is correct. And again, this is in certain situations. It depends on the lesions are the degree of narrowing or the number of vessels involved as to whether we prolong the life of the patient with coronary bypass. <v Speaker>And this patient who has two vessels who supply the entire left ventricle. I think we are prolonging his life. On the other hand, a patient who has one vessel that supplies only a relatively small amount, then surgery can only be used to help chest pain. <v Speaker>A couple of other points with respect to cardiovascular medicine, the operation that we're talking about tonight, as we mentioned at the beginning of the broadcast, is but one of the various types of palliative procedures that are available. There are others, for example, dilating or literally trying to squeeze open that obstruction with a balloon catheter technique known as angioplasty. How does a cardiologist go about deciding which technique one should use and realize it's on a case by case basis? What are some of the considerations? <v Speaker>Well, balloon angioplasty, as you know, is a relatively recent innovation, whereas coronary bypass has been with us since probably 1968. I think we're still developing our criteria for which patient is a candidate for balloon angioplasty. We started out with selecting patients who had single vessel disease, who had localized disease, who had what we thought were young lesions. That is not real hard and calcified lesions. And the results in those patients are fairly good. On the other hand, we have broadened in some centers are indications for this procedure and done patients with multiple vessel disease and harder lesions. The results naturally can't be as good in those patients as. And the first group.

<v Speaker>OK, let me interrupt just quickly, we do have a telephone call coming in from New Jersey. A woman has a question and I would like to take that call right now. Yes, ma'am. Go ahead, please. <v Speaker>Second, we're off the heart lung machine now. I just want to let you know we are on the progress of the operation now. The heart is beating on its own. We're off. The heart lung machine. And we'll ask Dr. Dyas now to give the medication which will begin to clot the blood. So are you receiving those phone calls and answering the questions? We'll go ahead and start to take the cancer out of the heart so that we can go ahead and give the proteome in which we stop the bleeding.

<v Speaker>Incidentally, the heart is being, as you can see, at a faster rate now and beating more vigorously and does not appear to be as dilated as it was before. And this, I think, is related to the fact that it's had a little time to recuperate from this period of lack of blood supply. <v Speaker>All right. We're going to go ahead and take that telephone call from New Jersey. Yes, ma'am. Would you go ahead, please, with your question? <v Speaker>And had one daughter who's thirty nine years old, he was told he had an aberrant, circumspect birth like that to fly.

<v Speaker>So about. <v Speaker>We had a bit of difficulty hearing that complete question. I believe the question concerned an aberrant circumflex at birth and presumably the gentleman died at the age of 39. Perhaps you might want to try to comment on that. <v Speaker>Well, Hatboro Circumflex may be related to what we were talking about in this patient. You may have origin of, for instance, a portion of the left coronary artery from the right aortic sinus, namely the right aortic sinuses where the right karner artery usually comes off. If this vessel. It's a left karner artery passes from the right aortic Santurce, a cross between the aorta and the pulmonary artery. Then there may be some compression of this vessel. And this can result in death. And there are a number of cases in the literature. But this is a very unusual condition. But this may be what she's talking about. <v Speaker>So if we wanted to generalize that question, what we're saying is that as what by whatever mechanism, if you pinch off in some fashion, those coronary vessels, you can create a steamier death. It doesn't just have to be from internal blockage. You could literally squeeze one of them shut. And that would do just as much damage.

<v Speaker>Correct. But the commonest cause is hardening of the arteries to the heart. Bikaner arteries. Sure. <v Speaker>Not to kind of tell you what we're doing now. <v Speaker>I don't think we'll give any blood during the operation, Dr. Dyson. We given any blood. <v Speaker>We've not given any blood during the operation. We may not even need to give any blood for the rest of the case. <v Speaker>It wouldn't be too uncommon for us to do this kind of procedure without giving any blood whatsoever. Very hands about how many species back there now, Gary? I have 400 species left. He has about 400 species of blood left in the box. Nader. He is slowly going to give that blood is we're giving the problem and to reverse the coagulation effect. It will be a few minutes here allowing the blood to be put back into the patient so we don't need to give any blood transfusion during the procedure. You can see the blood level on the reservoir. Now we're down to about 200 species left in. We might take a good look at the electrocardiogram and the pump pressure. Now, the patients are, of course, entirely on his own since we're off the heart lung machine. Duck dies. Can you show us on the screen what we have now to look at the patients generating the blood pressure? <v Speaker>About one hundred and fifty five, over 80 electrocardiogram. Here is a normal sinus rhythm. Very satisfactory. The central venous pressures in the normal range here, very happy with this board here, patient.

<v Speaker>Dr. Dias, we have a question coming in from Boston and we'd like to take that call right now. Please go ahead. Thank you. Hi, my name is Dr. Stone. <v Speaker>I'm a dentist from the Boston area. <v Speaker>And I have a question about a patient who has recently had an MRI about four months ago wondering since leading a relatively low and that she does have some coronary artery occlusion to have. <v Speaker>One cardiologist says, well, things look pretty neat to know. What are the specific indications under which you'd like to go ahead and do surgery? And secondly, both of them, I got the complication rates during surgery as opposed to someone. <v Speaker>Thank you.

<v Speaker>Well, the first question regarding regarding a patient who's had a heart attack or a myocardial infarction. <v Speaker>The answer to this question would be depend on which cardiologist you ask. Some cardiologists would say patients who have a myocardial infarction should have an angiogram to see what the coroner arteries look like. The reason being that even though one vessel may have resulted in the heart attack, the other two vessels may be involved as well. Other cardiologists would say one should follow this patient. If the patient has no symptoms, take care of the risk factors and try to do as much as possible along that line. If the patient develops symptoms, then we have another crossroads where one cardiologist might say, at this point, let's do an angiogram and see what the coronary arteries look like. Another one might say, let's treat the patient with medicines and we have a number of good medicines to alleviate the symptoms and follow the patient until the medicine's no longer work. So that I think this is the reason that you have two opinions from these cardiologists. As far as a decision as to when to operate, this, again, is based on the patient's symptoms and on the angiogram. And of course, until one does, this one doesn't know the answer to that question. <v Speaker>Well, thank you for that. Excellent question, sir.

<v Speaker>Given all the blood back to the patient now, the pressure is very satisfactory. And what we'll do is take out this cannula or the tube that we had in the ass in your order that was returning the blood to the patient during the procedure. Right. Take that out. We merely take the slow rubber tube off and then we'll pull the catheter out of the aorta and secure the knot down around the original circular first string that we put into the acid. <v Speaker>What we're doing this Dr. Dyche, continues to give the economy how much care do not recognize that we're given out. We're almost getting a call. About two thirds of the proteins in it'll be in very quickly. <v Man 5>Dr. Kinard, a quick question while they're working. Will those sutures dissolve? <v Dr. Kinard>Some of the uh most of the sutures which he's placing now will not dissolve. They're made of a plastic material, uh which does not dissolve, but also does not create a a reaction from the body. <v Man 2>And along those same lines. Another question from one of our viewers. Uh the attached vein essentially then heals itself to the heart. Is that correct?

<v Dr. Kinard>Yes. Initially uh the attached vein, there are clots formed in the needle holes. Then as time goes by, there is actually a new lining formed along the inside of the vein and at the connections to the aorta and to the coronary arteries. <v Man 2>How long a time period are we talking about here for the healing process? <v Dr. Kinard>We're probably talking about uh two to three weeks. <v Man 2>And all this time during the healing process, um it is those sutures that we've been talking about that keep that hydrostatic head up and keep that blood flowing and those sutures keep the uh vein graft from leaking? <v Dr. Kinard>Correct. The sutures also uh frequently are aligned with the endothelium or the inner lining of the all the vessels in the body. <v Man 2>One other technique that we might mention before we get back to the operating room is a uh use of a relatively new drug on the scene known as streptokinase. Now, we we mentioned that uh part or at least some of the heart attacks might be caused by a blood clot that could form in one of these abstructions. Perhaps you go through the limitations of the use of streptokinase?

<v Dr. Kinard>Well streptokinase is a chemical which dissolves clots within the body. And sometimes when a heart attack occurs, it occurs because usually there is a progressive narrowing of a vessel and it reaches a point where there's very little flow. <v Speaker>And some of the muscle dies, but not necessarily all of the muscle. But a clot forms in the final opening of the coroner artery. At this point, if one puts a catheter into the artery near or at the clot and injects the streptokinase. <v Speaker>This clot can be dissolved and flow can resume through this admittedly narrow coronary artery. But more flow than the none which was present previously, and therefore, one may say, some of the heart muscle that might have died because the clot was formed. Now, this does not prevent the initial problem of a smaller area of heart muscle.

<v Speaker>It dies, but it may save. Some of the muscle is still there. One still has to later do something about the obstructive narrowing to maintain this frequently. So the limitations are really related to the fact that some of the damage has already been done when one uses this form of therapy. <v Speaker>There is also a time limitation on the use of streptokinase, is that correct? This clot forms shortly after the onset of symptoms. And if one does not get the patient within the first few hours after the onset of symptoms, then all of this muscle that we're talking about may be able to be saved, is lost. So that depends. <v Speaker>Anywhere from two to six hours is the limit of time beyond which stripped Ichinose treatment is simply not indicated or unnecessary. That doesn't help. Doesn't help.

<v Speaker>Stepped Ichinose is another relatively new procedure as his balloon angioplasty. It is a sort of a noninvasive procedure in that it doesn't require surgery. It just does require an incision similar to a heart catheterization. <v Speaker>Most of the the techniques that you've been mentioning, the nonsurgical techniques really are not the kind of techniques that are the most commonly applied. We mentioned early on in the broadcast that the greatest majority of operations involving the heart are these coronary bypasses. I wanted you to give us some idea approximately of the percentages of cases that are amenable to bypass and those that might be amenable to angioplasty or other treatments. <v Speaker>Well, that that's a little difficult question. But if you use the original QUAT criteria for balloon angioplasty of a single vessel, that's a new lesion, then probably within a year you may find if you're doing, say, 500 patients in a year, you may find two, three or four patients who require balloon angioplasty or who it might be indicated.

<v Speaker>On the other hand, out of those 500 patients, you may find 350 that could be benefited by coronary artery bypass surgery. <v Speaker>Well, we have another caller on the line, a lady from Indianapolis, and we'd like to take that call right now. Yes, ma'am. Go ahead, please, with your question. <v Speaker>Yes, my question is. I was wondering with the heart set, because they've opened it up. Does it have to be sewn back together or will it grow back itself? <v Speaker>Rick, we routinely will close the pericardial sac around the heart. We don't close it very tightly, but we will close it. It will protect the bypass grafts. And it also has the advantage that if we ever in the future have to do another operation, there'll be a good sac around the heart to be easier to do. The operation itself won't be closed currently, but at least because loosely around the heart. <v Speaker>Thank you for that question, ma'am.

<v Speaker>Dr. Dietrick, let me follow up on that. It is often true in at least surgery in the abdomen, that adhesions form, that is to say, small sticking problems occur between organs. Is this also true in cardiovascular surgery? <v Speaker>Yes, sometimes we see that, particularly after a patient has had a heart attack. There adhesions. In fact, the case we demonstrated a couple of days ago showed the adhesions between the surface of the heart and the pericardial sac. There also will be some of those adhesions form around this heart and pericardial sac as the healing process goes on. <v Speaker>We have another caller on the line. We'd like to give him an opportunity to call. This is a local gentleman from Phenix, Arizona. Go ahead with your question, please. Yes, hi. <v Speaker>I'd like to know, how is the transition between the heart lung machine and the patient's heart completed successfully after having the patient's heart stopped beating for so long of amount of time without the oxygen to it? <v Speaker>I think I discussed that at the time. What we did was slowly decrease the rate of the heart, lung machine, the pump. At the same time, we're watching the arterial pressure and the venous pressure on you. So the scope at the end of the table, once we saw that the patient's pressure was satisfactory on his own. Then Gary shut the pump off completely. Well, thank you for that question, sir. Rick, we've essentially completed the bypass part of this what is left now is, of course, to close. There are a lot of people involved in a hard team like this. And I like to take the opportunity to thank our own team here and to tell you the members of the team. And we can kind of go around the room and show the function that they had at the head of the table cause was Dr Nelson Dyche, who is giving the anesthetic we reported to the blood gases and the pressure and so forth. Right next to him is Steve Valetta, one of our monitoring technicians. Steve, you might show right in front of you what you've been doing in terms of drawing the blood gas, is checking the Phenix pressure and so forth. Here you have our arterial pressure going after this can draw blood. Yes. Here is another team to drill here for a fracture. OK. He's demonstrated that you could hear what Steve was saying, but he's showing the various pressure transducers that we use back here at the operating table on my left. The girl who is holding a heart. She had a long job because we showed it to those bypasses into the heart. Here's Paul Sodersten, one of the nurses here at St. Joseph Farmers who has been on the cross for me. Doctor, by there, who is the associate surgeon next to him, Dr. Silca. Am I right? Dr. Bar bothers you. They were involved in retrieving the vein graft early. The person who is passing the instruments throughout the case was Betsy Craig's bar next to her in the back table. First was Patti Thompson, who earlier demonstrated the instrument to you, in addition to those persons who are scrubbed in, are sterile at the operating table as necessary as part of our team. They have persons who are not sterile and who bring the instruments into the operating table, pass them to these sterile person. Did you call circulate nurses? Robert Laffoon at the foot of the table was the circulating nurse on this particular case. And of course, finding Gary Mendell back at the heart lung machine whose was our cardio perfusionist, it was his responsibility to monitor the care of the perfusion throughout the time we were on Bifur.

<v Speaker>Dr. Dietrick, that's quite a crew. Let me ask if that is the standard number of people that you have in coronary bypass surgery.

<v Speaker>Yes, this is the team that we work with each day, five, six or seven operations in the beginning at six o'clock in the morning. That's quite a workload. <v Speaker>I take it you're waiting to make sure there's no more bleeding from the pericardium in the heart. <v Speaker>At the present time as well. <v Speaker>Yes, after kind of we've checked all your ask the most. He's now. In fact, everything looks very dry. We might want to show one good final shot. Nick Williams is our overhead photographer on the boom. Vic, you might want to come down on the heart one time so our viewers can see how beautiful the heart is, the beautiful color and the function as these bypass grafts are working very satisfactory. New blood into the heart muscle. We don't have any other final questions about the details of the operation itself, Dr.. I think we'll go ahead and begin to close the incision. <v Speaker>We have one. One final question from some of our viewers. It's apparently a question that has been repeated several times. So I'll address it to either you, Dr. Conrad, or Dr. Dietrich in the operating room. The question is, is fundamentally this why go to the trouble of bypassing the coronary artery with a graft when, in fact, you might try to essentially surgically remove that plaque? Can an artery be cleaned out? In layman's terms, as opposed to being bypassed?

<v Speaker>The answer to that is yes, it can be cleaned out. And it's been done in other arteries for insula. For instance, the carotid arteries are usually cleaned out and a patch made out of a Dacron material is placed in these arteries. Sometimes we clean out arteries in the heart. For instance, we sometimes do what's known as a gas and or direct tomie, which means dissecting of this atherosclerotic core out of the vessel. Then usually what we do is go ahead and do a bypass to that vessel. Anyway, we found that just cleaning out the vessel does not give nearly as good long standing results as doing a bypass to the vessel. We went through this in the early experimentation of relief of this obstructive process, and we found that the best way is to bypass rather than to clean out in the time we have left. <v Speaker>I'd like to talk a little bit more about the surgical technique. Perhaps you could give us a bit of historical background. Clearly, thousands and thousands of these bypass operations have been done. It must have started out as an experimental procedure. How long have we been doing this?

<v Speaker>Since probably 1968 or thereabouts. It started out as an experimental procedure. And of course, there were a number of experimental procedures that preceded the bypass graft, some of which worked to greater or lesser degrees. But the bypass graft was the the answer the best answer we have to the present time for this atherosclerotic disease. As we said earlier, both veins and the internal mammary artery had been used and have proved successful. The other types of bypasses that have been done have sort of fallen by the wayside because they're not nearly as successful. <v Speaker>I stepped aside from the operating table. I'm still in the operating room here. But in our view box, I've made a little drawing of what we found at the operating table, and I might be able to show you exactly what we saw as Dr. Conrad explained, the right coronary artery. This particular patient was extremely small and was not supplying much oxygen to the heart muscle.

<v Speaker>The left coronary artery began like this is a left main coronary. And then the anterior descending came right down the middle between the right ventricle and the left ventricle. And this had a very tight narrowing. If you remember, we made an incision in his artery about at this point and we passed the dilator up the artery. We could feel that obstruction. So the first bypass graft we brought in then was down to the anterior descending coronary artery. I'm sorry, that marking pad is not showing it too well, but I think you can see the location then. These circumflex coronary was a major coronary coming around and it sent off a large branch, which we saw here, a proximal branch and then secondary branches coming from that. So we bypassed do this part right here. This was the second bypass surgery before. Not sure that shows well with a pen. And then the third bypass down to the branch here that came directly from the circumflex coronary. So this is why we call a triple coronary bypass with one bypass, the second bypass and the third bypass graft here. I think that explains to you the procedure we perform. <v Speaker>But to clarify, you did not perform it in that sequence. You did the circumflex bypass first and then the enter descending bypass. That's correct.

<v Speaker>One question that we are always curious about when you go in, it is unlikely that you will find any surprises. Does the arteriogram usually do a pretty good job? That preliminary moving picture, x ray, does it do a pretty good job of showing you just what you need to do as opposed to going in and finding something a bit, to your surprise? <v Speaker>Yes, the majority of time we find that the Archigram is very precise in showing us where the narrowing is and where to bypass fractured and go. I would say, as a general rule, if there is any surprise for us, it is that the disease or the narrowing of the coronary artery is more advanced or to a greater degree than what we had anticipated from the Archigram. <v Speaker>And of course, the reason for this is that we compare a disease area which is obviously narrow to what appears to be a normal area, but that normal area may have disease as well.

<v Speaker>So you have no original standards, so to speak, with which to compare arteriogram. As Dr. Dietrick continues to bring this to a close. Let me ask you a bit about the future. <v Speaker>Can you peer into the future just a bit and see where we are going in terms of correction of cardiovascular disease beyond surgery? I'm sure that that will always have a place. Where are we going beyond that? <v Speaker>Well, there are a number of procedures that have been experimentally started. And, of course, you recently had some experience with this laser beams, which in animals may prove to be helpful, but there are considerable problems associated with that at the present time. <v Speaker>So I think it's a good period of time before we are to the point that we use this in humans.

<v Speaker>We have a number of exciting drugs on the market now for the treatment of symptoms of Karner disease. Again, I should stress we don't have any drugs that will take away arterial sclerosis. We have a few instances of people who've actually had some regression of Karner arterial disease. This is unusual and no one has been able to prove that any regression is due to any medicine or any diet or any thing else that's being done for sure. I think the future of Karner disease eventually is prevention. We have a number of things that we're doing along that line. We have some reduction in the incidence of heart disease. We think that may in part be related to some of the things we're doing, but where we don't really know enough. I think at the present time to entirely prevent coronary disease. So we continue to have to do these things which are palliation. <v Speaker>We've been talking all night long about risk factors and for the benefit of our audience. And we do not completely understand what you mean by risk factor.

<v Speaker>We are talking about those those things in our lifestyle, either over which we have no control, such as hereditary factors, predisposition to heart attack, or those things over which we do have some control, smoking, obesity, high blood pressure. Could you characterize for us briefly the smoking gun, if you will, what seemed to be the most crucial factors in a person developing coronary artery disease? <v Speaker>Well, I think we have to turn that question around and say, what factors can we modify and show a difference in mortality? And there are only two of those. One is smoking and the other is blood pressure. All right. If we have a patient who's had a heart attack, two patients. Yes, both stops. One stop smoking. The other doesn't. The person who stopped smoking lives longer than the person who doesn't. The same is true of blood pressure. If we modify blood pressure and patients who've had heart attack to normal as opposed to not treating it, then the patient lives longer. <v Speaker>We have another caller on the line from Georgia, and I would like to take that call right now. Yes, go ahead, please.

<v Speaker>The heart is involuntary muscle cars. <v Speaker>Well, the heart of coursed embryo logically develops out of a tube originally. And, of course, if you look around at various file an animal, you can see variations in the way that the heart developed from a tube to a four chambered collecting area that pumps vessels have muscle within their wall. Just as the heart has is a muscle itself. So it's just progressively turned on itself and in large that muscle. So it became the pumping chamber embryo logically and follow genetically. Well, thank you for that question. <v Speaker>Dr. Dietrich appears still here in the operating room with a closer look.

<v Speaker>To go to the screen again at the head of the table and have Dr. Di showing a blood pressure cardiogram there, entirely satisfactory. <v Speaker>It's a very nice view to see the expression your peer pressure. Can you demonstrate that force at the top of the. <v Speaker>So let's go one more time. <v Speaker>Yes, we can show you here the blood pressure is a hundred and forty over 80. The heart's working very, very well. Electrocardiogram is as normal a normal sinus rhythm. We call this the central venous pressures, normal, normal range. <v Speaker>Our blood gases is the last blood gas that we had here shows that the patients, P.H., seven point three seven. Just very, very mild illnesses. Acid side. But still within the normal range, hemoglobin is ten point one. And I have elected to go ahead and get two units of packed sales to give the patients some extra oxygen carrying capacity. <v Speaker>Dr. Dayas, we might mention that that number was originally around 15. And the reason for that dilution was because the pump itself was primed with a fluid, but not with blood.

<v Speaker>Yes, that is correct. This patient went even without us giving any additional blood. The hemoglobin will come up as the kidneys give off more urine and concentrates the fluid that's left in the body. <v Speaker>Now, put Dr. Diyas during the procedure. That's a very important number for us to know. <v Speaker>You're an out during the pump run, which was 57 minutes. Well, 700 species. There's been an additional 700 species since we came off the bypass. So the total urine output has been about two leaders. <v Speaker>That's very satisfactory for this particular stage of the operation. <v Speaker>Dr. Dyas, one quick question. You are now artificially ventilating that patient. He is no longer on the bypass machine. So we presume you are breathing for him? <v Speaker>That's correct, Rick. I'm breathing for the patient now with the ventilator here. Here's the ventilator here. You probably can't see that very well. Here's the flow meters. During the bypass procedure, we're on the farm. The ventilator is turned off. The patient's not ventilator at all. I turned the ventilator on as soon as we started coming off bypass.

<v Speaker>And that's essentially a pump also, which compresses and expands gas, which flows into the lungs. <v Speaker>It's a bellows arrangement, Rick, with compressed air compressing the outside of the balance and the inside of the bellows being delivered to the patient. <v Speaker>Well, thank you, sir. Dr. Dietrich, we have about one one minute left in the broadcast. I wondered if you would like to at this time present us with some closing or closing comments? <v Dr. Edward B. Diethrich>Yes, Rick, I just step- stepped out of the operating room now. Uh you can see the team behind us here uh they're putting in the final stitches to close the uh chest. I think as we anticipated earlier, this is a very important educational experience for laypeople, uh perhaps as well for some medical people. I wanted to take this opportunity to thank the public television station, KAT Channel 8 here in Tempe, Arizona, for the splendid cooperation they have given us. I think they have given an opportunity for us here in the operating room at St. Joseph Hospital to show you a unique adventure in terms of what the human heart looks like uh when it's beating. I hope you agree with me that it is a beautiful organ and it's wonderful to have the opportunity to repair this and bring more blood supply into the heart muscle. We're looking forward to this patient's total rehabilitation. And we'll catch up with you in the intensive care a little bit later this evening. Thank you very much. [music plays] [audio and video cut out] <v Narrator 1>[program restarts] An 8 Alive Pacific Mountain Network special. Major funding for The Operation has been provided by a grant from the International Heart Foundation with additional funding provided by Bard Cardiopulmonary Division of C.R. Bard Incorporated, Bio-Medicus Incorporated and Shiley Incorporated, Irvine, California. [music plays]

<v Dr. Edward B. Diethrich>Good evening. Over the past 10 years, we have used television extensively to educate nurses, technicians-