Hybrid procedures are gaining ground

Thomas J. Hoey had already suffered two heart attacks when a stress test last summer revealed new blockages in his heart, including one in his left anterior descending artery - the so-called widowmaker, or LAD.

His cardiologist told Hoey he needed heart surgery, but the 60-year-old from Drexel Hill balked at having his chest cracked open, the traditional way the surgery is done.

After some research, Hoey found another way: hybrid surgery.

"My rationale was, the less invasive, the better," he said.

For Hoey, the hybrid approach started with three small incisions enabling a surgeon to insert a bypass around his clogged LAD. A few weeks later, a cardiologist followed up by threading tiny metal scaffolds called stents through blood vessels to open two other blockages.

His case underscores how heart care is evolving. For more than a decade, surgeons doing open-hearts have competed for patients like Hoey with interventional cardiologists, who implant stents.

And the surgeons have been losing ground. Since 1997, the number of heart bypasses in Philadelphia and the four Pennsylvania suburban counties has fallen nearly 57 percent, to 2,602 in 2008, an Inquirer analysis of hospital billings found. In the same period, the number of procedures that implanted one or more stents rose nearly 24 percent, reaching 10,611 by 2008.

Proponents such as Hoey's surgeon, Francis Sutter at Lankenau Hospital, say hybrid heart procedures, which can be done on one day or in stages over several weeks, offer the best of both approaches.

"There is no question in my mind that this will be the future," Sutter said.

The technology exists to fix clogged arteries with minimally invasive approaches. Robot-assisted surgery enables incisions to be made smaller when compared with full open-heart surgery. This allows for quicker recovery, he said.

And with the advent of drug-coated stents that reduce the risk of reclogging, Sutter said, many patients will do well without resorting to traditional surgery. "Patients don't want their chests cracked," he said.

Others say there is no scientific evidence that most patients fare better with the combined approach.

"The garden-variety patient is probably more easily treated by one procedure rather than mixing and matching procedures or . . . putting them through multiple procedures," said Michael P. Savage, director of the cardiac catheterization lab at Thomas Jefferson University Hospital.

Savage said a few patients would undoubtedly be well-served by hybrid procedures, such as those too old for open-heart surgery. But he was skeptical of their value for most others. "Quite frankly, I think this whole idea is driven by marketing," he said.

Hospitals across the region are moving to build or plan hybrid operating rooms that combine the sterility and instruments of an OR with the imaging equipment and radiation shielding of a cardiac-catheterization lab, where stents are inserted.

Jefferson operates a hybrid OR. The Hospital of the University of Pennsylvania opened its first hybrid in 2005 and is building a new one.

Penn Presbyterian Medical Center also has one. Cooper University Hospital opened its first hybrid operating room last month.

Michael Rosenbloom, head of the division of cardiothoracic surgery at Cooper, said that besides unblocking arteries in the heart, a hybrid approach is useful in treating a patient with valve problems and a clogged artery.

He can replace the valve with minimally invasive surgery, and a colleague can place stents to address the blocked artery.

At Chester County Hospital in West Chester, cardiac surgeon Martin LeBoutillier and interventional cardiologist Timothy Boyek are collaborating on staged hybrid procedures to replace valves and insert stents.

In the next three years, the hospital expects to build at least three hybrid heart ORs in a new hospital building. The advantage, the doctors say, goes beyond the combined procedure to, for example, the rare instances when a patient getting a stent needs emergency open-heart surgery.

"All of these rooms will have the capability for open-heart surgery," said LeBoutillier.

Companies are rushing to help surgeons replace heart valves by using catheters, delivering the new valves through the blood vessels in the same way stents are now placed. That's another reason the hybrid ORs are likely to multiply, Rosenbloom and others said.

Last month, the U.S. Food and Drug Administration approved the first such device, sold by Medtronic.

Another similar device, from Edwards Lifesciences Corp., is being developed and tested at Penn and other medical centers across the nation.

Joseph E. Bavaria, a heart surgeon at Penn, said that ultimately the development of hybrid techniques would foster better collaboration between surgeons and cardiologists, leading to improved patient care. And the combined procedures would save money.

"It takes two admissions down to one" when they are done the same day, Bavaria said.

The federal Medicare program pays hospitals an average of between $30,683 and $53,395 for a valve operation, depending on a patient's severity.

A heart-bypass payment to hospitals ranges from $18,408 to $40,943 on average. And the newest stent procedures cost between $8,912 and $15,795.

Those payments do not include payments to surgeons or adjustments that hospitals get for serving underinsured patients or training young doctors.

For hybrid procedures during one hospitalization, Medicare and private insurers would pay a single rate equaling the single most expensive procedure - not for two separate procedures.

"The only way for a hybrid program to be successful . . . is if you have a very high level of teamwork and collaboration between cardiology and cardiac surgery, which have sometimes been competitors for patients," said John Byrne, chair of cardiac surgery at Vanderbilt University Medical Center in Nashville.

A prominent advocate of the combined approach, Byrne argues that hybrid ORs provide surgeons with the imaging tools to check their work before closing the patient, and make surgery possible for older patients and others too sick to undergo open-heart surgery.

"We are all treating the same problems; we just have different sets of tools," he said in a recent interview.

Byrne also advocates performing the hybrid procedures during the same OR visit, thus reducing the number of times a patients is under anesthesia and the chance for mishaps when a patient is transferred from one place to another.

Others counter that because patients who get stents must be on anticlotting medication, doing the procedures at the same time raises the risk of blood loss.

While the debate in the medical community is likely to continue - until researchers can determine the benefits and risks of hybrids compared with other approaches - patients such as Hoey aren't likely to wait.

"The procedure was very simple from my point of view," Hoey said of his minimally invasive bypass.

The retired music teacher was discharged two days after the surgery and was able to play his trumpet within a week.

He returned to Lankenau two weeks later and received two stents to open his other blockages.

"I was delighted that it just took days for recovery, instead of months," Hoey said. "I would highly recommend it to anybody that has to have heart-bypass surgery."