ROY GOLDFARB IS A RETIRED PHARMACY EXECUTIVE from Boca Raton, in his early seventies, a large, good-humored man with a lovely smile; he is also very sick. It is early February 2006, about seven-thirty in the morning, and I’m watching him being wheeled into a cardiac operating room at the New York–Presbyterian Hospital/Columbia University Medical Center in New York City, or “Columbia-Presbyterian,” as the staff call it.
Operating rooms, “ORs,” are alien places—all shining surfaces and blinking monitors in bright, dead light. Like most surgery patients, Goldfarb has been tranquilized for his trip to the OR, and with good reason: lying amid the liana forest of glistening tubes and wires, surrounded by masked figures, staring up at the intense surgical lamps, is akin to the nightmare fantasies of a UFO abductee. Goldfarb has also been warned by his surgeon, Craig Smith, that while this operation is viewed as a “safe” one, the chances of a “major adverse event”—death, a stroke, kidney failure—are about 4 to 5 percent. And since Goldfarb has had heart surgery before, he’s had firsthand experience of the injuries that are about to be inflicted upon him. He knows that he will wake up hours later in major pain, that it will be some days before he will be able to get around by himself, that he will feel weak and exhausted for a month or more, and that some after-effects, like memory problems, could persist for a year. But he also knows that he has a diseased heart valve that has imposed an unsustainable burden on his heart, and that if he doesn’t get it fixed, he’ll die.
Like many heart patients, Goldfarb suffers from a variety of “comorbidities”—his speech is slightly slurred by Parkinson’s, he has diabetes, and he takes at least a dozen prescription medications. But the reason his Florida cardiologist recommended that he fly to Columbia-Presbyterian for his operation is that he is a “reop.” He had bypass surgery a dozen years before, and his chest images show large white smears of sticky postoperative scar tissue that pose special challenges for a surgeon.
Columbia-Presbyterian—along with the Cleveland Clinic, the Texas Heart Institute, and perhaps a dozen others—ranks among the elite cardiac surgery centers that regularly receive difficult cases from other heart centers. Heart surgery volumes have been trending down in the United States, but Columbia-Presbyterian’s volumes rose strongly in 2005 to nearly 2,000 cases, about an 18 percent increase. It has special capabilities in pediatric surgery and performs more heart transplants than any other center in the United States. Smith has been chief of the cardiothoracic division for the past ten years, and has been on the Columbia faculty for more than twenty. A former college football and lacrosse player, he is a lean and athletic-looking fifty-seven. Although he is reserved almost to the point of shyness, Smith is a fine public speaker and found himself much in the public eye in 2004, including a stint on Larry King Live, after he performed a quadruple bypass operation on former President Bill Clinton. Smith’s name shows up consistently on “best doctor’” lists, and he was recently chosen “practitioner of the year” by Columbia’s physician association. In early 2007, he received a special honor from the American Heart Association for his “contributions to cardiovascular medicine and science.” Clinton himself made an unannounced appearance to present the award. He said presenting it made him the happiest person in the room “because I’m still alive.”
Surgical repair of human hearts first became practical in the early post–World War II era, and the techniques spread rapidly in the 1960s. Heart surgery set the pattern for the spectacular high-tech American style of attacking disease—spectacular in execution and expense, but often in results as well. The heart was the ideal early target. Its detailed physiology is still being unraveled, but in principle it is the simplest of organs: a four-chamber pump that operates much like any other pump. It is also very hard to break, because its electrical engine is distributed through every cell of the myocardium, the thick wall of muscle that surrounds the heart’s chambers. (“Myocardium” is Latinized Greek for “heart muscle,” a remnant of the old expectation that doctors speak Latin.) Myocardial cells are uniquely designed to beat, and only to beat, for as long as they live; drop them into a petri dish, and they beat all by themselves—it’s just what they do. The heart can therefore withstand the grossest of insults—cut into a heart, stick tubes into it, twist it into a ball—and for the most part it keeps on beating.
The heart’s pumping sequence is straightforward. The right side of the heart collects blood from the venous system and pumps it into the lungs to be reoxygenated. The left side collects blood from the lungs and pumps it through the body. Each side has two chambers—an atrium where blood is collected, and a ventricle that does the pumping work. The largest and most muscled chamber is the left ventricle, for it must deliver the powerful contractile thrust that drives the blood, up to six gallons a minute, through thousands of miles of vessels before it returns to the right atrium for recharging. While healthy circulation requires that all four chambers work well, failures in the left ventricle are usually the most immediately life-threatening, and the most frequent targets of surgical interventions.*
The valve that brought Goldfarb to the OR is his aortic valve. It sits at the crucial junction where blood flows from the left ventricle into the aorta, the sluiceway into the body’s arterial system. The aorta is an enormous blood vessel that rises several inches straight up out of the heart and then arches sharply downward. The valve is a simple ring with three overlapping flaps that are locked in the closed position until they are blasted open by the surge of blood from the ventricle. The ejected blood fires through the valve straight up into the aorta, hits the arch, and bounces back on the valve flaps, slamming them shut—an elegantly simple and efficient design. Goldfarb’s valve, however, is encrusted with thick deposits of calcium that prevent it from fully opening at the outward surge or fully closing on the bounce-back. Not enough blood is getting out of the ventricle and too much of it is regurgitating back in, so the ventricle is working far too hard, under internal pressures that are far too high—a recipe for lethal heart failure.
When Goldfarb is wheeled into the OR, he is met by an assistant surgeon, a physician’s assistant, two anesthesiologists, and two OR nurses. The prep work takes about an hour. Goldfarb is anesthetized, shaved, and painted almost head to toe with bright red antiseptic; various monitoring leads and cuffs are affixed around his body, breathing and imaging tubes pushed down his throat, a flow monitoring catheter is threaded through the jugular vein into his heart, and a urinary catheter into his bladder. He is wrapped with yards and yards of sterile tape and gauze; his eyes are taped shut.
Before starting the surgery, the team must create a “sterile field,” an invisible space surrounding the operating table. (Invisible, but known to everyone except me, the first time I was in an OR. I unwittingly started walking toward the edge of the field and was almost tackled by the head cardiac nurse, Flora Wang.) Within the field, “Surgeon’s Rules” apply. No one may enter without first scrubbing hands and arms in a deep tub of antiseptic soap, and donning a long-sleeved, floor-length sterile surgical gown and sterile wrist-covering surgical gloves. All instruments, monitoring leads, and tubes that pass through the field must be sterile. At one point in the surgery, the physician’s assistant, Debbie Savarese, brushed against a table outside the field. She immediately turned and raised her arms, and the nurse pulled off the surgical gown and helped her into a new one—just that slight brush was contaminating.
Goldfarb himself must be sterilized. A sterile plastic sheet is laid across his body and pressed down until it sticks like a second skin—the incision will be through the sheet. His entire body, including his face, is completely encased in sterile paper sheeting and dozens of blue OR towels. Anyone walking into the OR at that point would see only a mound of blue cloth, with an open, flesh-colored, plastic-covered strip about two feet long and six inches wide at the apex of the mound. The “scrub” nurse, who will work inside the field, rolls the instrument array—which she had arranged within a mini sterile field of its own—to the foot of the operating table and takes up her position on the right side. A plastic sterile sheet is raised behind Goldfarb’s head. The sterile field is in place. Not everyone works inside the field. The anesthesiologists can operate all their monitoring and infusion equipment from behind the sheet, and do not gown. Flora Wang, who is serving as the “circulating” nurse that day, also stays outside the field. I am positioned with the anesthesiologists, standing on a low stool so I can see over the sheet directly down into Goldfarb’s chest.
Raising the sheet palpably changes the tone in the room, like the pivotal rite in a religious ceremony. I’ve seen some noncardiac surgeries that were almost rowdy—loud rock music, locker-room jokes flying. But not in cardiac ORs. Some surgeons are notably more talkative than others, but once the sheet is up, the intense concentration imparts a note almost of solemnity. Mauricio Garrido, the assistant surgeon, has told me that cardiac surgery is one of the few procedures in which you are aware, at every moment, that your patient is at risk of sudden death; even simple mistakes can kill. Or as another surgeon, Allan Stewart, put it, “In heart surgery, the complications come at you very fast.”
Smith arrives a few minutes later, quickly scrubs and gowns, and takes the lead surgeon’s place on the right side of the table. Both he and Garrido wear bright headlamps and goggles with a jeweler’s eyepiece for each eye. Garrido is the senior cardiac surgery resident, a fully qualified surgeon, who is completing two years of advanced training in heart and lung surgery. Normally, assistants open the chest, and Garrido has opened hundreds. But Goldfarb’s opening poses special challenges, so Smith will lead it. The old bypass scar tissue in Goldfarb’s chest has glued his heart to his chest wall, and the kind of saw used in a normal opening could wreak havoc. Even worse, one of the old bypasses—a vein graft that carries blood around a blocked coronary artery—snakes back and forth beneath the breastbone, or sternum, but Smith isn’t completely sure of its location, so he has to be extra cautious.
Garrido makes the initial chest incision, using an electric scalpel that singes the flesh as it cuts—much as Western heroes cauterized their bullet wounds with branding irons. The smell of barbecued meat wafts through the room. Smith then goes to work on the sternum, using a small-bladed circular saw, working slowly, from the top down, with increasingly delicate strokes as he gets closer to the chest cavity.
When the sternum is finally split through, he and Garrido cautiously spread the halves a few inches apart and expose the solid mass of scar tissue. The two begin to “make a plane,” separating the heart from the chest wall by cutting laterally along the inside of the wall. They cut from either side in tiny eighth-inch strokes, one of them bracing the chest as the other cuts. At one point, Smith takes two grapples, with blunt, rounded, claws, and hooks them under the chest wall. Then, neck muscles bulging, he leans back with his full weight to pull up his side of the chest to give Garrido a better working view. Garrido cuts for a while, then takes the grapples and does the same for Smith. As they gain separation, they insert a metal jack, or “retractor,” and ratchet the sternum wide open—it looks slow and smooth, but I can feel the violent stretching and bending of the chest bones.
Making the plane takes almost two hours. During all that time, Smith and Garrido almost never speak, and take no breaks. Smith stretches his neck exactly twice, each time almost guiltily, suddenly arching his head back and flexing his shoulders in a one-second spasm. And they never deviate from the tedious rhythm of cautious, one-eighth-inch scalpel cuts.
There is a fleeting crisis. As they are almost finishing their plane, the anesthesiologist, Mark Heath, who is watching the EKG readout, says “Fib!” It’s not loud, but it’s sharp. I get out of the way: Goldfarb has fibrillated—instead of beating in rhythm, his heart muscle fibers are fluttering in aimless confusion. There is a flurry of motion: Wang sprints to the front to hand Smith electrical paddles from a defibrillating machine. A jolt from the paddles, the heart jerks, quivers, and resumes beating. Smith watches it for a few seconds, then he and Garrido resume their work.
Except for a couple of terse commands from Smith, no one has said anything. I had moved off to the side by the blood-bypass machine, and Allison Cohen, the bypass technician, or “perfusionist,” said to me with a smile, “Well, that was mildly exciting.” Her face was flushed and the smile looked nervous, but I assumed she really meant “mildly,” for that was my impression. I had clearly seen an “event,” but the team had moved quickly—I guessed the elapsed time at only twenty seconds or so. There was no shouting, and it all felt very controlled.
Later, I asked Smith. “Mildly exciting?” he said, “—no, that was frightening.” Yes, your heart can stop for brief periods, he explained, but with a valve like Goldfarb’s, it is very dangerous. The calcification on Goldfarb’s valve stiffened it and made it hard to open. “My hands aren’t strong enough to squeeze the ventricle and force open that valve,” he said, “and the ventricle was still filling with blood. Another few seconds, it would have started to swell like a balloon, and nothing kills heart cells faster. We were, maybe, thirty seconds away from a fifty-fifty mortality situation. The bypass wasn’t set up yet, so if the defibrillator hadn’t worked right away, I would have had to crash on bypass through the groin. We had the equipment in place to do that, but it’s a bloody, dangerous procedure, one that you really want to avoid.”
How frightening? I asked. Once a week frightening? Once a year? Smith thought a bit—“About once a month.” I asked why it had happened. “I don’t know,” he said. “It doesn’t happen often—although we’re always prepared for it—and it’s hard to trace to specifics.” Making the plane, he went on, required a long period of cutting around the pericardium, the sheath that encases the heart; conceivably, that could have disrupted the heart’s electrical signals. But there was no way of knowing for sure.
When their “plane” is finally in place, Smith and Garrido prepare Goldfarb’s heart for surgery. They slice open the pericardial sac and tie it back to expose the beating heart muscle, sequester chest arteries and lungs with a few large sutures, then insert the large tubes, or “cannulae,” that will connect Goldfarb to the bypass machine—one is placed in the right atrium to intercept venous blood and shunt it to the machine, and a second is plugged into the aorta, to bring freshened blood back to Goldfarb. A second, smaller set of cannulae is placed in the aorta. After Goldfarb goes on the bypass machine, they will deliver “cardioplegia” into the coronary arteries to shut down the heart’s beating and protect the myocardial cells. As the cannulae are being placed, Heath starts heparin infusions to prevent clotting during the surgery. When Goldfarb’s clotting time registers about five times longer than normal, it is safe to go “on-pump.”
Going on a bypass machine is routine in the sense that it takes place throughout the world literally thousands of times a day, but is never standard, especially if, as in Goldfarb’s case, there is the danger of a sudden backup of blood. For almost ten minutes, Smith and Cohen go through a delicate series of maneuvers, easing open the bypass cannulae, while they alternately fill and drain the heart, until it is completely empty and circulation is under the control of the machine. Smith announces “Cross-clamp” and applies a large clamp that completely shuts off the aorta just below the bypass cannula. Cohen starts the cardioplegia, and Goldfarb’s heart jitters to a stop. She flips a switch to turn on a blood-cooling device to lower Goldfarb’s body temperature, which reduces the risk of prolonged surgery. Heath turns off the ventilator, or breathing pump, and Goldfarb’s lungs deflate. For the duration of the operation, the bypass machine will detour Goldfarb’s blood around his heart and lungs, process it through a series of vertical spinning cylinders where it will be mixed with air, and pump it back into the aorta.
It is now more than three hours into the operation, and the valve replacement can finally get under way. Smith makes an incision at the base of the aorta to expose the aortic valve. He probes the thick encrustations of calcium, then like plumbers repairing an old pipe fitting, he and Garrido chip away calcium, carefully removing any stray pieces—floating calcium debris could trigger a stroke. They then slice out the three valve leaflets and trim back the white, rubbery ring that they sit on, leaving just enough to anchor the new valve.
Goldfarb had chosen a replacement valve derived from a cow. It won’t last as long as a purely mechanical model, but avoids the necessity of a lifelong anticlotting regimen. For a flat, firm valve placement, the suturing must be straight and kink-free, and Smith and Garrido take elaborate precautions against tangles. They space twelve separate sutures, in alternating blue and white, around the rim of the empty valve opening, each one pulled through the rim and folded back on the towels in a double strand. As they finish a set of four, they cover it with another towel. Both ends of each suture are then stitched through the sewing ring around the outside of the valve. Smith carefully pushes the valve down the columns of sutures into the valve opening and presses it firmly in place—it is by that point only partly visible. He takes each suture pair, holds it up for the nurse to clip off the needles, and, his fingers a blur, ties a triple square knot that slides down tightly to the top of the valve ring. When he finishes, Garrido sprays away accumulated blood, while Smith uses a probe for a long, careful, inspection of each of the attachment points. The two then reseal the aorta with two layers of closely spaced, evenly slanted continuous stitching, much like that on the outside of a moccasin.
Cohen has already started warming the bypass blood, and as Goldfarb’s temperature rises back to normal, they ease him off bypass—essentially reversing the process of going on-pump. Cohen washes out the cardioplegia and flushes warm blood through the coronary arteries. Goldfarb’s heart immediately starts to quiver. Smith eases up on the aortic cross-clamp, while Cohen slowly closes off the venous cannula, redirecting blood back into the heart. Heath restarts the ventilator, and Smith opens a small tube he prepositioned in the heart to bubble out accumulated air. As soon as Goldfarb’s heart fills with blood, it jerks back to life, beats strongly for a few minutes, then starts jumping erratically, registering rounded, somewhat incoherent lines on the EKG. Smith applies pacing wires, and the EKG readings quickly shift into the evenly spaced, sharply pointed profile of a normal heartbeat. Cohen turns off the bypass, and Heath injects a heparin antidote that almost instantly drops Goldfarb’s clotting time back to normal.
For several minutes everyone focuses on the echocardiogram image of the new valve, as Heath manipulates the receptor in Goldfarb’s throat to show it from different angles. It’s clearly a good valve, opening and closing smoothly and tightly. Smith makes one last inspection of the aortic stitches, then he and Garrido start extracting the bypass tubing and closing the incisions. Remarkably, Goldfarb has not needed a transfusion. Blood accumulating in his chest cavity has been siphoned out to the bypass machine, where it has been cleaned and added to the bypass volume. In a good heart center, most patients lose very little blood.
Garrido and Savarese handle the cleanup and chest closing, although Smith checks on their progress from time to time. It takes about an hour—taking out the temporary sutures, removing the multiple absorbent cloths and towels in the chest cavity (especially checking that no blood-soaked, bunched-up cloths are jammed beneath Goldfarb’s heart), installing pacing wires and a drainage tube through Goldfarb’s chest, reinspecting each stitching site.
Finally, Garrido removes the chest retractor and starts placing a row of heavy stainless steel sternal sutures, pushing them up from under the sternum on each side, and twisting them closed at the top. When they are all in place, Goldfarb’s chest still gapes open by several inches. Using a heavy pliers, and starting from the bottom, Garrido tightens each twist, slowly tractoring the two sides of Goldfarb’s chest back together. Garrido is stocky and strongly built, but Goldfarb is a big man: it takes about ten minutes and a half dozen passes to get a tight closure. The last step is to stitch shut the chest flesh over the sternum. The stitching is in several layers, with Garrido and Savarese each working from a different end of the incision to the middle. All of the stitches are subcutaneous, so when I saw Goldfarb a few days later, his chest showed only a narrow red line with no stitch markings. The flesh stitches will degrade and be absorbed over several weeks, but the sternal sutures are there for life.
By the time the stitching is finished, the transport team has arrived from the ICU. Shifting dead weight like Goldfarb’s from the operating table to a gurney would be tricky under any circumstances, but is made doubly so by the drips, tubes, wires, and machinery still attached to his body. Between the transport team and the OR team, there are eight people in the room. They all take positions around Goldfarb and with a “One-two-three-lift!” move him onto the gurney. In the ICU, Goldfarb will be settled in a bed, attached to a range of monitors to track his circulation, heart performance, and other vital functions, and checked for any signs of bleeding or excess drainage. A painkilling drip will be attached to his chest; when he is stable and his bleeding under control, he will slowly be awakened from the anesthesia. It is well past noon when the gurney leaves the OR, some five hours after Goldfarb’s arrival. My back and legs are painfully stiff from the hours of standing, but Garrido and Savarese have one, and possibly two, more operations to go. There is time for a bathroom break and a quick snack before getting back to work.
Goldfarb was released from the ICU after the standard two days. The next stop was a “step-down” unit, roughly the same as a normal hospital floor, but with double the nursing ratio. I visited him there on “POD 4,” or the fourth postoperative day. He was sitting in a chair by the bed, eating lunch. He was clearly weak, but compared to my last image—mostly of a bloody hole atop a mound of blue towels—“weak” looked pretty good. Pain was not much of a problem, he reported, although his chest was stiff and sore. His Parkinson’s medication hadn’t been resumed right away, so his hand tremor had returned, but was already getting better. I asked about his breathing. He said, “Before the surgery, I couldn’t walk a hundred yards. I think I could walk around the block right now.” And he was in fact already walking regularly on the floor and doing breathing exercises. This was a Thursday; he expected to move that day or the next to a regular floor. Assuming no setbacks, he would be discharged the next Monday to his daughter’s apartment in New York, where he would stay until he could return to Florida.
I stayed for about a half hour. We talked mostly about the pharmacy business: he explained how the government was destroying neighborhood druggists by pushing Medicare clients into mail-order programs. But his manner was relaxed and smiling, belying his words. The surgery was over, he was going to be fine, and he was able to sit and talk about business. He looked like a happy man.
I called his daughter’s apartment about three weeks later to see how he was doing. A booming male voice answered. I said, “Mr. Goldfarb?” He sounded nothing like the Mr. Goldfarb I had met before the surgery. Yes, it was Mr. Goldfarb, and he was doing spectacularly well. “I’ll be grateful forever to Dr. Smith for fixing my valve,” he said, “but the nutritionist at the hospital changed my life.” All patients meet with a nutritionist before they leave the hospital; she told him she had just visited a man his age who had not managed his diabetes and was now a quadruple amputee. “She scared the hell out of me,” Goldfarb said. “I’ve never paid attention to my diabetes. I never checked my glucose, I took the same medication every day, and I ate what I felt like.” Since the surgery, he had lost 23 pounds and was planning to keep it off. He was tracking his glucose religiously, and his cholestrol was down to 152. He was walking around his daughter’s neighborhood several times a day. Even his sciatica was gone! “I’ve been given a second chance,” he said. “Actually, it’s your third,’” I said. He laughed, “You’re right. It’s my third. But it’s finally gotten through to me, and I’m going to make the most of it.”
The total cost of Goldfarb’s surgery, including a reasonable allowance for aftercare, was about $65,000. But if the cost is measured per “quality year” of life gained for patients like Goldfarb, it would be well under $10,000. Most economists say that’s a bargain, although many still worry about its affordability. We will come back to the question of affordability in the last chapter. But the ability even to perform procedures like Mr. Goldfarb’s didn’t just happen. It is the consequence of a purposeful, highly focused, public-private research effort that stretches back a half century and beyond.