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This article by Kathleen McGinn Spring was prepared for the June 12, 2002 edition of U.S. 1 Newspaper. All rights reserved.
The Heart to Heart Low-Down on Cardiac Care
It started out as an easy assignment: Find out what
cardiac services area hospitals offer. Now it is two weeks, 10 legal
pads, 16 interviews, one morning in a cardiac catheterization lab,
and one open heart surgery (not my own) later.
There have been tales of the keen frustration of a hospital that won
an eight-year battle for approval for a heart hospital, but can’t
attract nearly enough patients. And a tale of the equally keen frustration
of another hospital, just across town from the first, which can not
get the approval, and is watching helplessly as hundreds of its patients
cross the river into Pennsylvania. The invasive cardiac procedures
these patients receive there are among the biggest money makers for
hospitals — surpassing all other procedures by a wide margin.
Cardiologists and cardiac surgeons have used the terms "vendetta,"
"bad blood," "kickbacks," and, most daunting of all,
"business as usual" to portray the patterns of referrals that
determine which heart patients are treated where.
Beyond where patients are treated is the question of how they are
treated, and the two are linked, with the "where" often determining
the "how." Among the issues are whether a bypass operation
should be done on or off the pump, in other words, whether new veins
and arteries should be grafted into place while the heart retains
its job of circulating blood throughout the patient’s body, or whether
the heart should be stopped, its flow clamped, and its work taken
over by a machine.
Another issue is whether to harvest the saphenous vein, which runs
from the ankle to the groin and is often used as a conduit to by-pass
a blocked artery, by making an incision along that entire length,
or whether the vein should be pulled out through two or three small
These debates surround one of the most invasive cardiac procedures
— a bypass operation, which makes an end run around a blocked
artery by grafting veins and/or arteries from the patient’s body onto
his heart arteries. There are also substantial differences of opinion
on cardiac catheterization, often a precursor to bypass, and the only
procedure that gives cardiologists a good look at the three arteries
leading from the heart and at their many branches.
Every hospital in the greater Princeton area has cath labs that perform
catheterizations on low risk patients, but only a few can perform
the procedures on high risk patients or can perform angioplasties,
which are catheterizations that reopen arteries by partially inflating
them with a balloon and inserting a stent to hold them open.
The Journal of the American Medical Association (JAMA), however, has
recently published a much-quoted study stating that the first line
of treatment for heart attack should be angioplasty — a procedure
few New Jersey hospitals are allowed to perform — rather than
the clot-busting drugs that most now administer.
The JAMA study was featured prominently on the front page of the New
York Times on April 17. The headline: "A call for change in cardiac
care — researchers say best option is hospital doing angioplasty."
In the article, Lawrence K. Altman wrote that "while not definitive
by itself, the study confirms and adds to 20 consecutive earlier ones
that have shown the superiority of opening clogged arteries with balloons
and other devices as the initial therapy (for heart attack) rather
than using clot-dissolving drugs like plasminogen activator, or T.P.A."
Altman noted that "in an editorial accompanying the new report,
Dr. Christopher P. Cannon, a cardiologist at Brigham and Women’s Hospital
in Boston, wrote that government and public health and other government
officials needed to develop a system to treat heart attack patients
modeled after the one used to send injured patients to trauma centers
instead of community hospitals."
Should our community hospitals gear up to perform angioplasties, the
most difficult cardiac catheterizations? Can they? Alternatively,
should ambulances drive past our community hospitals and deliver heart
attack victims to the nearest hospital with a full-service cardiac
department? In central New Jersey, that could mean driving past the
Medical Center at Princeton to get to St. Francis in Trenton or Robert
Wood Johnson in New Brunswick.
For greater Princeton area Baby Boomers, these questions are not academic.
Heart disease is Mercer County’s number one killer. What’s more, the
incidence of the disease is higher in Mercer than it is in New Jersey
as a whole, and, in turn, New Jersey’s rate is higher than the national
average. Lifestyle, say our cardiologists and hospital administrators,
is the reason. Hectic schedules lead to more fat-laden prepared foods
and restaurant meals, and cut down on time for jogging, gardening,
and going to the gym. Arteries are clogging, and the age at which
men and women are developing heart disease is dropping, making it
important to know what cardiac service choices are available, and
the pros and cons of each. Here is a look at what greater Princeton
area hospitals offer, and what doctors and administrators say about
the future of cardiac care in central New Jersey.
Some states do not regulate cardiac services. New Jersey
"In New Jersey, it is tremendously difficult to get a heart surgery
program," says Judy Persichilli, CEO of St. Francis Hospital in
Trenton. Persichilli, intelligent and animated, started her career
as a St. Francis nurse and is passionately committed to the hospital,
and to its mission of serving every patient, regardless of financial
resources. A graduate of Rutgers, who earned a masters in healthcare
at Rider, she is determined, too. It took her eight years of relentless
lobbying and persuasion to win the certificate of need — granted
by the state’s Department of Health — that allowed St. Francis
to open its heart hospital.
After the Department of Health turned her down once, Persichilli lobbied
each and every member of the health committee of the New Jersey Assembly
and persuaded them to draft a bill endorsing a heart center at the
hospital. It passed 37-1, the Department of Health reconsidered, and,
five years ago, Persichilli began to build her program.
Her first move was to recruit Dr. Glenn Laub, who had been performing
heart surgery at Deborah Heart and Lung Center in Browns Mills for
10 years. Laub holds a bachelor’s degree from Yale, received his medical
degree from Dartmouth, and did his residency at New York University’s
Bellevue Medical Center. At Deborah, he was co-director of surgical
Laub brought his team with him, and not just his assisting surgeon,
anesthesiologist, nurse, and respiratory therapist, but also his secretarial
and clerical help. "The first person we operated on at St. Francis
was operated on by a team who had done thousands of procedures,"
says Laub. Persichilli rounded our the cardiac team with about 25
more hires, creating a "24/7" shop. She made room for a heart
center wing, which contains a cath lab — soon to be joined by
another — an operating room, recovery room, and state-of-the-art
equipment. Initial cash outlay came in at about $8 million.
The program has been a success in every way but one. Laub is one of
only three cardiac surgeons in New Jersey whose outcomes are rated
better than expected. His risk-adjusted mortality rate, stated in
a report by the Department of Health, which issues detailed report
cards on the state’s cardiac programs, is better than 49 of the state’s
52 cardiac surgeons. The hospital as a whole achieved a high ranking
in the latest report card, too, bested by only two of the state’s
other 16 full-service heart centers, and then only by a fraction of
a percentage point.
"We had no deaths in our first year," says Laub. "Our
mortality is low. Our complications are low. Our re-admits are zero."
Yet the program, which got off to a faster than expected start, doing
175 procedures in its first year, has stalled. "It should take
three years to get to 350 (procedures)," says Laub. "We’re
The reason, he and Persichilli agree, is a pattern of referrals by
cardiologists, the doctors who manage heart disease, but do not operate.
A man whose default expression is a wide smile, Laub’s easy laugh
covers an intensity that flares quickly when he speaks of the 52 percent
utilization rate of his heart hospital, a rate that puts it well below
the 350 procedures a year that the state considers essential for a
"Princeton does not refer to us," says Laub. The only exceptions,
he says, are uninsured patients. Capital Health System does not refer
to St. Francis either, he says. The bulk of St. Francis’ referrals
come from Robert Wood Johnson in Hamilton, and that, according to
Dr. Tyrone Krause, chief of cardiothoracic surgery at Robert Wood
Johnson University Hospital in New Brunswick, is because a large group
of Hamilton cardiologists has poor relations with the staff at their
sister hospital, his home base. "There’s bad blood," says
Krause, "a vendetta."
Laub also refers to this dark underside of referral patterns. He says
financial and political motivations are at work when some cardiologists
send patients out of state. He has talked up his program to every
area cardiologist. "I’ve taken them to dinner," he says."I’ve
played golf with them," he jokes, "even though I play badly."
The hospital has posted billboards on and near Route 1 depicting Laub
and his personable staff in scrubs, and touting the rankings its heart
hospital has achieved. None of it has helped. Despite Laub’s golf
dates, and Persichilli’s charm, drive, and passion, the program remains
Persichilli and Laub are convinced that patterns of
referral alone are to blame, and Krause of Robert Wood Johnson in
New Brunswick, adding credence to the referral problem, says cardiologists
are sometimes drawn by "kickbacks," which, in this context,
he describes as, perhaps, free physician’s assistants and prime scheduling
in operating rooms and cath labs.
Persichilli says her hospital’s city location, between Trenton High
School and the Chambersburg section of Trenton, does not deter patients.
But, in fact, patient comfort may play a role. "It’s like Newark,"
Krause says of St. Francis. "You need a shotgun to get in the
door." The perception may be false, but it is hard to deny that
That said, I easily found on-street parking near the hospital, as
I have a number of times before, and strolled in without encountering
gun play — or feeling threatened or uncomfortable in any way.
A bypass operation began shortly after I arrived, and Laub invited
me to observe. Jumping at the chance, I pictured myself standing behind
glass watching from 20 or 30 feet away. When nurse Tory Johnsey led
me to the nurses’ locker room and outfitted me in green scrubs, I
began to think I was going to get a closer look. In addition to the
scrubs and booties, she gave me a mask, explaining that the plastic
portion extending from just over my nose to the middle of my forehead
was to keep blood from splashing into my eyes.
Johnsey expressed some concern, instructing me to let someone know
if I began to feel faint, but I assured her I would be fine. When
I entered the O.R., however, I took one look at the patient’s leg
and suddenly was not so sure.
Robert Clancy, co-coordinator of the bypass team, a graduate of Trenton
State, and one of the first registered nurse first assistants in New
Jersey, had cut the leg open from ankle to thigh, and was probing
around inside it for the vein that would be used to bypass the patient’s
clogged artery. I tried not to look at the leg. The cut was so deep,
and so raw. It was easy to imagine how much it would hurt.
For a minute I stood just inside the O.R. door, near the perfusionists,
who were operating a heart/lung machine about the size of a large
toy chest on casters. The machine, from which a large number of plastic
tubes snaked six or seven feet to where the patient was lying, was
substituting for his heart and lungs, drawing blood from his upper
heart chambers, passing it through an artificial lung to oxygenate
it, and returning it to his body.
I thought that might be my spot, near the heart/lung machine, and
not all that far from one of the O.R.’s two doors. But Johnsey whispered
that I could stand on a stool directly behind the patient’s head,
and inches from his chest. I moved into position, keenly aware that
any misstep off my stool would not be good for any of the machines
surrounding the table, not to mention the patient. I was oh-so-careful,
keeping my hands clasped behind my back to ensure I would not interfere.
The chest had been cut open, its two halves spread far apart by a
sturdy, square vise. The patient’s heart, still because the heart/lung
machine had taken over its functions, looked enormous, the size —
and color — of a roaster chicken, or at least two-thirds of a
"Is that heart unusually big?" I whispered to the Dr. Michael
Thorogood. The team’s anesthesiologist, he is a graduate of the University
of Virginia Medical School and trained as an anesthesiologist at the
University of Pennsylvania. During the bypass operation he stood directly
behind me, monitoring banks of gauges. "He’s a big man," Thorogood
laughed, "he needs a big heart."
Thorogood, tall and imposing, with a calm, easy manner, and kind eyes
above his mask, was a big man too, and I guessed he could easily bail
me out if I did begin to feel queasy. But all I felt was fascinated.
Laub was sewing the patient’s mammary gland onto his heart. Dr. Joseph
Costic stood across the table, assisting. A graduate of Notre Dame
and the New York College of Osteopathic Medicine, Costic did his postdoctoral
training at the Michigan Health Center, and completed his cardiothoracic
surgery fellowship at Deborah. Like Clancy and Thorogood, he began
working on Laub’s team long before Laub was recruited by St. Francis.
As Laub and Costic worked silently, a nurse stood behind Laub’s left
shoulder, motionless for a very long time, his arm extended, and his
hand holding the heart still while Laub worked on its back side, attaching
the mammary artery.
While the mammary artery’s strength makes it ideal for use in bypass,
it does not reach far. Veins do not hold up as long as the artery,
about seven years as compared with 10 to 15 for the artery, Costic
told me, but they have a much longer reach.
Laub, wearing glasses with microscopic attachments for the close work
he was doing, finished grafting the mammary artery. By then a long
vein — thin, blue, and oh-so-fragile — was draped over the
patient’s open chest cavity.
The room was nearly silent as Laub worked, stitching the vein into
place. There were 12 people in the O.R., saying little but "yes,
sir" in response to Laub’s requests for an instrument to be brought
over or for the table to be rotated — at the press of a button
by one of the anesthesiologist’s assistants — to give him a better
angle of vision.
The air of still concentration was a surprise. I had expected something
more M.A.S.H.-like, with music, jokes, and kibbitzing, but all was
After Laub completed the vein graft, he restarted the heart. Then,
after the heart had been jumping around energetically for a number
of minutes, he told me the time had come for the test of the operation’s
success. The air of intensity in the room deepened. The big moment
had come. He took the patient off the pump, letting blood course through
his heart’s new conduits. They held. And the mood in the room lightened.
Soon after that, Laub left the O.R., his part of the operation over.
The music — Motown — was turned on. I guessed the choice was
Clancy’s, because he alone hummed quietly along and moved to the music.
Masked, scrub-swathed members of the team began to move in and out
of the room, and conversations began, but still quietly. Clancy sewed
the leg back together. "That will hurt more than the chest,"
Costic said of the leg wound as he worked at the chest cavity, mopping
up with gauze as a nurse used what looked like a turkey baster to
irrigate it again and again.
He cauterized any areas that were still blending, using a heated instrument
that filled the chest cavity with wispy smoke and sent up an odor
like that of a dentist’s drill. The heart was beating now, pretty
wildly, actually jumping around. I had asked Costic earlier about
whether he thought it better to operate on the pump, which stills
the heart, or off the pump, which is said to reduce the chance of
stoke and post-operative cognitive difficulties. I had heard that
he and Laub had performed the first off-pump operation in New Jersey
while they were at Deborah.
"Can you imagine sewing a vein onto a heart moving around like
that?" he asked as the large organ all but danced in the patient’s
Before closing, Costic placed a long, blue string into the patient’s
chest, explaining that it could be used later on, if needed, to guide
a pacemaker into place. Then he looped another blue string around
the new vein. It would be a marker, showing up on any further catheterizations.
Then he wiped each side of the breast bone clean, and using a big
hook, threaded wire in and out of the breast bone to close the chest,
giving the wire a long, strong yank at the end, before sewing the
skin back together. He then drove three, long, sharp-tipped plastic
tubes into the skin under the patient’s chest. "These are for
drainage," he said. "I’ll take them out in his room."
It was past 4 p.m. The operation had lasted about three hours.
"He’ll be sitting up watching the evening news," Thorogood,
the anesthesiologist, said of his 80-year-old patient.
"How soon will he be back on the golf course?" I asked. "Oh,"
at least four people said in unison, all laughing, "he’s not a
Ah, so they knew something about the man on the table. That was tremendously
reassuring. Lying on the table, his faced buried under layers and
layers of blue cloth, his chest spread open, and his body still, the
patient looked barely human, but to his bypass team, he was an individual.
He was also a pretty typical bypass patient.
"The average age is 65 to 75," Costic said of the patients
on which his team operates. That is about 10 years up from the average
just a few years ago. The main reason is better angioplasty techniques.
Better management of anesthesia in the elderly is a factor too. The
oldest patient Laub has operated on was 97, and he made it through
fine. Thorogood, speaking quietly during the operation, told me about
a 94 year-old woman who underwent a bypass. "She was up and about
in a day and a half," he said, he eyes conveying the smile hidden
behind his surgical mask.
The operation over, the patient left for the recovery room, which,
at St. Francis, is right outside the O.R. He would be under the care
of his cardiac surgery team for two days.
On the way in, I had seen two women, one middle-aged, one older, sitting
on one of the recovery room beds. As I left, I wondered if they were
"my" patient’s daughter and wife. They had looked anxious,
and I smiled to think they would soon be watching the evening news
with their father and husband.
Laub and his team had given the man a crack at 9 or 10 more years
on earth. The team, which works so well together, may soon get the
help that will pull in more bypass patients. The boost comes in the
form of a brand new cath lab. As I was on my way to the O.R., I ran
into a state team doing a final inspection of the just-completed lab.
The hospital has had only one lab, working at well above expected
capacity, and Persichilli is counting on the second to bring in enough
cardiologists to up referral rates. She has created a new classification
for cardiologists, which will allow them to use the cath labs, but
will not obligate them to take on any hospital duties. Access to cath
labs is to cardiologists what rink time is to hockey teams. They do
not want to be stuck doing their procedures late at night or too early
in the morning. The new lab will create more attractive time slots.
"St. Francis should be helped by the new cath lab," says Dr.
Ronald Fields, director of the cardiac catheterization lab at St.
Mary Medical Center in Langhorne. "They did 1,500 catheterizations
last year. That’s a tremendous number for one room. We did 2,500 in
three rooms. You need to get a certain number of caths to get open
St. Mary, a few miles over the Pennsylvania border,
is where Capital Health System in Trenton sends the majority of its
heart patients for high risk catheterization, angioplasty, bypass
and valve surgeries, and implanted defibrillators. It has three cardiac
surgeons, three cath labs, two cardiac operating rooms, another operating
room that can be pressed into service if necessary, and an electrophysiology
lab. It provides every heart procedure but transplant.
Dr. Ronald Fields is director of the cardiac catheterization lab.
At St. Mary for 13 years, he is a graduate of LaSalle and Penn State
Hershey Medical School. He did his residency at Letterman Army Medical
Center in San Francisco and trained in interventional cardiology (the
training that allows cardiologists to perform catheterizations) at
Walter Reed Medical Center. Calm and sincere, he, speaks carefully,
weighing his words. Asked about the JAMA study, suggesting that angioplasty
should be available in every hospital as the first treatment for heart
attack, he says, "it’s a very delicate balance. There is a better
chance of opening an artery with angioplasty, but the drawback is
that if you don’t do a lot of them, it’s hard to do them well."
It comes down to large matters and small, and some factors few people
would consider. Yes there has to be a lab (cost, about $1.5 million),
and an experienced surgeon, and a substantial, skilled back-up team,
but there also has to be equipment — a staggering amount of expensive
equipment. "If you just do the procedure once in a while,"
Fields says, "you can’t afford to stock all the equipment."
Every heart is different, Fields explains, so not every guide wire,
stent, catheter, and balloon — the basic equipment used in catheterization
— will fit every patient. Not uncommonly, the first catheter,
or the first stent, is not the right size, and another has to be tried.
To illustrate, he leads a tour of St. Mary’s cath lab, busy on a recent
day performing procedures in all three rooms, many on patients who
looked well shy of their 50th birthdays.
Pausing at a six-foot-tall rolling cart, he says, "These are the
balloons. Stacked four deep and about 10 high on each shelf, the balloons
bear numbers like 2.0, 2.5, 3.25, and 3.75, indicating diameter, and
numbers like 9, 15, 20, and 30 millimeters, indicating length. There
were hundreds of them. "Each one costs a couple of hundred dollars,"
He walks down a long hall, past supply cart after supply
cart. He opens tall, double doors to reveal still more catheters,
stents, and guide wires. He pokes his head into packed supply closets,
and points to shelves full of equipment in the cath labs themselves.
Along the way, he mentions that each of the hundreds of stents on
hand cost $1,200, and that the guide wires come not only in a variety
of length, but also in a different ranges of flexibility.
Most community hospitals would be hard-pressed to come up with such
a stockpile — or to find a place to stash it all. Drawing from
a smaller number of supplies, they could perform angioplasties, and
could get good results in some, but, Fields says, if the equipment
used in an angioplasty is not the best fit, results are not going
to be as good.
Earlier, in a phone interview, he had used a shoe analogy to explain
the catheterization process, saying that just as feet come in different
sizes and shapes, so do hearts. Looking at a computer monitor displaying
a detailed image of a heart he had just catheterized, it quickly became
clear that the analogy did not even come close to describing the idiosyncrasies
of each heart.
"The blockage is easy to see," Fields says. It is. The artery
and its many branches, which had been injected with dye during the
catheterization, looked like so many dark, twisted tributaries of
a great river. At one point, the dark flow line of the river stopped
almost completely, narrowing to a pencil-thin white line.
As Fields was pointing to the artery’s main blockage, Dr. Haji Shariff,
one of St. Mary’s cardiac surgeons came to take a look. Shariff, a
graduate of the Institute of Medical Sciences in India, has completed
cardiothoracic surgery fellowships at St. Christopher Hospital and
at Hahnemann Hospital. The cardiac surgeons’ office is just yards
from the cath labs, giving St. Mary’s patients the same advantage
of close collaboration among members of the cardiac team that those
at St. Francis, Robert Wood Johnson New Brunswick, and other full-service
cardiac hospitals enjoy.
"He’s a 73-year-old guy with high cholesterol, untreated,"
Fields tells Shariff. "He needs a bypass. I couldn’t get that
diagonal," he says, "pointing to an especially convoluted
branch of an artery. "It goes backward before it goes forward.
"Do you think you can get the diagonal?" he asks Shariff.
"Sure," Shariff answers.
"I told the patient I’d rather do it sooner. He said `can you
do it today?’" he tells Shariff with a laugh. The surgery is not
an absolute emergency, but it is scheduled for the next day.
Shariff moves on to his next patient, and Fields continues to explain
what the monitor shows about how arteries work. "Each artery has
branches," he says. "That’s why you hear of people having
four or five by-passes. Blockages can develop at any point in any
of each artery’s many branches.
A number of tests, including C.T. scans and stress tests, can let
physicians know that blood flow from the heart is not what it should
be, but only catheterization shows the position — and extent —
of any blockages.
Results of about one-third of catheterizations show
that a stent — or perhaps a number of stents — are all that
is needed to restore normal blood flow from the heart. But in another
third of cases, the images show that the patient, like the 73 year-old,
has too many blockages, or has them in areas where it would be too
difficult to insert a stent, which Fields describes as a small wire
that resembles a section of chain link fence. In those cases, the
alternative generally is a bypass operation.
As Fields is deciphering his 73 -year-old’s artery images, Dr. Bradford
Sodowick, director of the electrophysiology lab, walks down the hall,
stopping to weigh in on the matter of where heart attack victims are
best treated. Sodowick, genial and relaxed as he discusses some of
the most devastatingly destructive tricks a heart can play, received
his medical degree from Thomas Jefferson University Medical College
and completed his residency at the University of Pennsylvania Hospital.
He completed a fellowship in cardiovascular medicine and clinical
cardiac electropsysiology at Yale University School of Medicine.
"No one can plan a heart attack," says Sodowick, whose lab
works on the electrical function of the heart. Some of his patients
are the Dick Cheneys, the people whose hearts are damaged, often because
of a previous heart attack. Others are individuals whose relatives
died very young — in their teens, 20’s, or 30’s — of a heart
attack. Sodowick’s patients are individuals at high risk for sudden
death from heart attack. Examples, he says, are young men who die
on a basketball court.
These patients often know they are at high risk for a heart attack.
Many other people, going about their business, are totally unaware
of creeping, silent heart disease.
"You can’t plan for a heart attack," Sodowick says. "You
want to seek out any treatment as soon as possible."
The JAMA article suggests that heart attack victims whose arteries
are opened by angioplasty as the first treatment for heart attack
have a better chance of surviving than do those who are treated by
clot buster drugs, the only option in all by 17 of New Jersey’s 82
Still, says Sodowick, "I tell my patients to go to the nearest
hospital. Period. If you can walk to Princeton Hospital, go to Princeton
So great is the psychological draw of the big city hospitals, though,
that he has had patients experiencing chest pain who drove from Princeton
to Philadelphia. He shakes his head at the folly, saying, "They
lost 55 minutes." Every one of those minutes is crucial. "We
have a saying," Sodowick says, `time is muscle, heart muscle.’"
If a patient lives halfway between a community hospital and a heart
center, Sodowick says the heart center is the clear choice. If the
distance to the heart center is slightly longer — maybe 10 minutes
as opposed to six — going those extra miles could be a good choice.
"I tell patients," says Sodowick, "be aware of the location
of the nearest tertiary hospital (one that specializes, in this case
in heart medicine), and know how to get there. When you’re having
chest pain, you don’t want to be driving and be on the cell phone
If symptoms are minimal, he says, it may be worth driving farther
to get to a hospital with full heart services. "Despite the JAMA
article," says Sodowick, "it’s a balance."
As Sodowick answers a page, Dr. Anil Deshpande, chief of cardiothoracic
surgery, steps out into the cath lab hall. Deshpande holds a medical
degree from T.N. Medical College in Bombay. He completed his surgery
training at Maimonides Hospital in Brooklyn, St. Francis in Trenton,
and at Hahnemann University Hospital in Philadelphia. Pausing, he
agrees to weigh in on another controversial subject — whether
bypass operations are best performed on or off the pump.
"We like to call it beating heart surgery," says Deshpande
of a procedure where a pump does not replace the heart’s function.
"Eighty to ninety percent of the by-passes done at St. Mary are
done without stopping the heart."
This method is technically more difficult, says Deshpande, "but
cuts risk of stoke in half — from three to four percent to zero
to two percent." It also, he says, reduces complications, substantially
cuts length of hospital stay, and reduces post-operative cognitive
problems, including short term delirium, confusion, and agitation,
and a more subtle loss of short term memory long term.
Nationwide, says Deshpande, only 30 percent of by-passes are now done
on beating hearts, but he predicts the percentage will double within
the next five years. There is now five-year data on outcomes —
on how well the grafts hold up — and results, he says, show no
difference in how well the new veins and arteries function. Sewing
new veins into place on a beating heart is not extraordinarily difficult,
Deshpande says. This is so, he says, because a multi-pronged instrument
— called an octopus retractor — keeps the heart fairly still.
If the data seven to 10 years out is as good as early
reports indicate, Deshpande says he expects that off-pump bypass will
become the standard of care, although cardiac surgeons at other greater
Princeton area hospitals disagree, saying early reports of the advantages
of off-pump bypass are faulty, or overblown.
Desponde says a reason St. Mary draws so many bypass patients —
350 last year and probably more than 400 this year — has to do
with its use of beating heart surgery. "Patients hear about it
on the radio," he says. "There was just an article last week
in the Wall Street Journal."
Another fairly new procedure St. Mary offers is minimally invasive
saphenous vein harvesting. Rather than cutting open a leg from ankle
to groin, the cardiac surgery team makes a fairly small incision at
the knee and the ankle, and sometimes makes another pinpoint incision
at the groin, and pulls the vein out. Again, says Deshpande, this
procedure is technically more difficult than the standard procedure,
but not only causes less pain in all patients, but also is a major
boon to the obese, to diabetics, and to anyone at high risk for infection.
Some question whether the quality of the vein is compromised by being
pulled out through a small incision, but Deshpande says it is not.
He and his team performed 45 by-passes last month, way above average
for the hospital, putting it on track to do 400 or more procedures
this year. A great many of those 400 patients will travel across the
Delaware from New Jersey to receive the procedure. Many will be people
who first sought treatment at Capital Health System in Trenton, where
Deshpande and his team also have privileges.
Capital Health System in Trenton is on track to do 500
low risk catheterizations this year. "Were it not for the limits
of the certification of need regs, our scope of services would be
greater, says Dennis Dooley, vice president of planning and development.
As it is, the hospital fumes as its cardiac patients cross the river
to St. Mary for their angioplasty, by-passes, and heart valve surgeries.
"We’re not on a level playing field," says Dooley. "Pennsylvania
has no certificate of need to curtail cardiac services. New Jersey
is well intended, but it is inhibiting our operations. Our admissions
are the 10th highest in the state. Our cardiac admissions are the
7th highest. We have a higher volume of admissions than eight of the
New Jersey hospitals that have cardiac surgery. Four hundred patients
in the last 12 months went to Pennsylvania because we were prohibited
from doing cardiac surgery."
Why didn’t some of these patients make the short drive across town
to St. Francis, a hospital that does have a full-service cardiac program,
instead of crossing the Delaware? A few did, Dooley says, but not
many. "The decision is controlled by the attending physician,"
he says. "A substantial and talented group of cardiologists have
privileges here and at St. Mary."
Without exception, cardiologists, cardiac surgeons, and hospital administrators
agree that a high volume of cardiac surgery equals high quality outcomes.
Even Krause, the Robert Wood Johnson New Brunswick head of cardiac
surgery, who performs 700 heart procedures a year, says he learns
something every week.
The certificate of need is an attempt to ensure that each hospital
performing cardiac surgery will have enough patients to keep their
interventional cardiologists, who do angioplasties, and their cardiac
surgeons, who do by-passes and other heart operations, busy enough
to become expert and to stay sharp. The theory is that prudent geographical
distribution will ensure high volume.
It turns out, however, that the theory is not working
in Mercer County. Human factors are getting in the way. Physician
referrals, as Dr. Laub of St. Francis has found to his great frustration,
are almost rock-like in their inflexibility. Cardiologists quickly
become defensive when asked about where they refer and why. It is
their choice, they say, and they guard that prerogative closely.
Patient perceptions also play into decisions on where to seek care,
and, for whatever reason, Capital Health System, a hospital without
a certificate of need for cardiac surgery, says it is drawing far
more candidates for heart surgery than is St. Francis, the area hospital
that does have the certificate of need, and is ready, willing, and
eager to treat each and every resident of the greater Mercer County
area in need of invasive cardiac procedures.
No matter, says Dooley, patients go where they want to go, and, he
asks: "Are the (cardiac) regs serving the people of New Jersey?
No, because of dislocation of patients. This is not about competition
with St. Francis," says Dooley. "This is about a natural population
of patients who are frustrated by their inability to get treatment."
Perry Durkin, Capital’s vice president for clinical services, says
her hospital has been aware for some time of the studies upon which
the JAMA article was based. "We want to be able to do angioplasty,"
she says. "We are ready and able to do that now."
A lot is going on in the hospital’s diagnostic capability, Durkin
says. "We’re acquiring expensive technology for cardiologists.
We have made purchases to get into the latest on the market. As we
come into the fall, Capital will be the first to have a PET scanner.
We do a tremendous number of nuclear tests. We’re setting the stage
for being ready."
"How much have we spent?" Dooley asks her.
"Well over $2 million," Durkin replies, "not counting
ultrasound and defibrillators."
A hospital must be doing 500 low risk angioplasties a year to apply
for a certificate of need. Capital is just about at that level now.
Is there hope that Capital will get a certificate of need for a full
"Oh, there’s always hope," says Dooley, with a cross between
a sigh and a growl, and a tone betraying more frustration than hope.
For now, Capital does offer low risk cardiac catheterization. But
since two-thirds of all cath patients will need a more invasive procedure,
sometimes immediately, why would anyone choose to have the procedure
at a community hospital, like Capital or Princeton, where angioplasty
can not be performed and there is no cardiac operating room?
"Numerous studies have shown it is very good medicine to have
your catheterization done first," says Durkin. Then, she says,
the patient can go home for a day, get his life in order, and assess
treatment options before checking into a hospital for angioplasty
or a bypass, if either is necessary.
Because a catheterization can reveal that the patient needs a further
procedure right way, says Durkin, "all cath labs have to be able
to manage a critical patient through transfer."
While this is the case, and every area community hospital has a protocol
for transferring patients who get in trouble during a low risk catheterization
to a heart center quickly, cardiac surgeons to a man say that if they
were going to have a diagnostic heart catheterization, they would
want it done in a hospital equipped to perform angioplasty and cardiac
surgery. "Things don’t go wrong often," is a typical comment,
"but when they do, they go wrong very fast."
Like Capital, Princeton Medical Center can do only low-risk
catheterizations. Dr. Andrew Shanahan is the hospital’s chief of cardiology.
He is a graduate of Georgetown and received his medical training at
the Medical College of Wisconsin. "Princeton has had a diagnostic
cath lab since 1997," he says. "It’s extremely safe, one of
the safest in the state. No deaths, thank God, in five years."
At Princeton, as at most hospitals in the state, "the primary
treatment for heart attack is clot busters," says Shanahan, "then
catheterization, then transfer."
In line with the recommendations in the JAMA article, does Princeton
plan to apply for a license to perform angioplasty? "The easy
answer is yes," says Shanahan, "but you have to move in steps
to move to a full cath lab."
Shanahan has been section chief of cardiology since January 1. "When
the administration asked me (about moving to a full cath lab),"
he recounts, "I said this is what we should be doing. The administration
is supportive. We are applying for advancement to high risk cases.
The next step after that is primary angioplasty."
Shanahan, who is certified as an interventional cardiologist, performs
angioplasty at Robert Wood Johnson in New Brunswick. He says transfer
protocol for patients needing cardiac services Princeton can not provide
depends upon the physician, the patient, and the family. He often
recommends Robert Wood Johnson, and says other physicians prefer Pennsylvania
or New York.
In some cases, he says, the choice is based on relationships a cardiologist
has with one of the big city hospitals, perhaps he trained there,
or knows cardiac surgeons there. In other cases, says Shanahan, the
choice is driven by patients, and especially by those who have moved
from New York, and want to return for their surgery.
Why do Princeton cardiologists not refer to St. Francis, the full
service cardiac hospital down the road? "For me," says Shanahan,
"it’s difficult to go to Robert Wood Johnson in one direction,
and St. Francis in the other. The vast number of my referrals go to
Robert Wood Johnson. That’s my practice scenario.
"Referral patterns," he says, "are the privilege of the
physician who refers. It’s as simple as that."
Robert Wood Johnson in Hamilton is licensed to do both
low risk and high risk catheterizations. "We don’t have the angioplasty
piece yet," says Debbie Cardello, chief operating officer, "but
we are requesting angioplasty certification."
Strangely, the hospital, which is affiliated with Robert Wood Johnson,
New Brunswick, is the only area hospital that sends a sizable number
of its cardiac surgery patients to St. Francis. "St. Francis is
very close," says Cardello. "It’s the closest, and it has
a wonderful unit. We feel very confident."
The hospital transfers about two patients a week, via ambulance, out
of its cath lab to a full-service cardiac facility. "The transfer
is never a problem," says Cardello. "They go on a stretcher
with a critical care nurse."
Like her counterparts at Capital and Princeton, Cardello says having
the initial catheterization at a community hospital is not a problem
for patients. If the patient can go home, he has time to consider
his options. "If a patient needs service," she says, "he
will get it as soon as possible." Her staff calls ahead to the
receiving hospital, asking if a room is free. If so, says Cardello,
"we bypass everything and go right to the O.R."
Persichilli, the CEO at St. Francis, says a patient leaving the cath
lab at Robert Wood Johnson Hamilton can be on the operating table
at St. Francis in half an hour.
Robert Wood Johnson New Brunswick, has the largest full-service
heart hospital in the greater Princeton area. It has three cardiac
operating rooms, five cath labs, four cardiac surgeons, and eight
Dr. Tyrone Krause is the hospital’s director of cardiothoracic surgery.
He is a graduate of New York University and of New York Medical School
at Valhalla. He received his training in cardiac surgery at Cornell
in New York City.
The state wants each of its 17 cardiac hospitals to do at least 350
heart surgeries a year. Robert Wood Johnson does 1,500, and 700 are
done by Krause himself, who averages three a day.
"You don’t have to go to New York or to Philadelphia anymore,"
says Krause. "The people get deceived a lot. Cardiologists will
tell their patients, `You have to go to him, he’s the best.’ People
don’t realize they have the right to do it anywhere. It’s their decision."
Krause takes great pride in doing complex, high risk heart operations
that others — including prominent New York City surgeons —
turn down. He says it is frustrating to hear patients say they want
to go out of town. "But," he says, "if a patient says
`I’d rather go to New York,’ the last thing I do is talk him out of
it. It’s a lose/lose. If the outcome is good, they’ll say `well, it
should have been.’ If the outcome is bad, you’re screwed. I say Go."
Krause believes more hospitals should be certified as heart centers.
"As many as can provide good service," he says. He gets 300
cases a year from Somerset, for example, indicating he says, that
Somerset should be able to do its own cardiac procedures. On the other
hand, hospitals that are not getting a large volume of patients, should,
in his opinion, close down their cardiac departments. Outcomes suffer
in low volume cardiac departments, he says, and the cost of running
such a department will make it a money loser.
Asked why St. Francis, located in a populous area, is having difficulty
pulling patients, Krause says, "Princeton Hospital sends a majority
of cases to Philadelphia, by-passing Trenton." Also, he says,
"I hear Trenton is not a nice place to go for your bypass."
But whether a patient does choose St. Francis, or Robert Wood Johnson
New Brunswick, or St. Mary, he is better off clinically, Krause says,
in choosing a full-service cardiac hospital.
"I trained at Cornell," Krause says. "Every patient came
from out of the city. If a patient dies, you don’t have to look the
cardiologist in the eye. If there is a problem with the wound, you
don’t have to look the cardiologist in the eye. Here, I have to look
the cardiologist in the eye. It takes the edge off when the cardiologist
is not around."
Krause also has strong views on the on-pump/off-pump debate, as well
as on the advisability of substituting minimally invasive vein harvesting
for the standard, open-up-the-length-of-the-leg procedure.
"I do pump," he says. "I can do a better job. I’m fast
and I’m accurate — one-and-a-half hours for a triple or quadruple
bypass. For slower people, off-pump may be a benefit.
"They have recently been rescinding some literature on the benefit
of off-pump," he says. "It was initially thought there was
less stroke, but now studies show no difference. The New England Journal
said there was faulty data on cognitive ability. These are not seven-year-olds.
Take a 70-year-old and look a year later. He may have lower cognitive
As for minimally invasive vein harvesting, he says, "sometimes
you can injure the vein. You don’t want to put in a bad vein. When
you open the leg and take tissue around the vein with the vein, you
hardly touch the vein. You get the best result."
Patients, he says, like the smaller incision that goes along with
minimally-invasive vein harvesting. "There’s a lot of pressure
to do these things," he says. "Everyone wants small stuff,
but the results are not as good.
"Cardiologists are hypocritical," he says, "they steer
patients toward the minimally invasive procedures, but when they need
an operation themselves they want it done the old way. They want it
No matter how a bypass surgery is done, the financial rewards for
the surgeon doing it are way down. Krause says he wanted to open his
own practice but discovered that he would need to bill $2,000 a procedure
just to break even. A few years ago, reaching that number would have
been a slam dunk. "Reimbursement was $8,000 to $9,000," he
says. But in the past few years, Medicare has dropped that amount
to $1,800. HMOs pay even less.
So Krause stays put. His hospital subsides him. This, he says, is
common practice. If hospitals want high quality cardiac surgeons,
they pay them a salary on top of the fees Medicare or private insurance
Dr. Charles Dennis is chairman of the department of
cardiology at Deborah, and he is also cardiovascular advisor to the
New Jersey Department of Health, the group that regulates cardiac
services in the state. He did his undergraduate work at Occidental
College in Los Angeles, graduated from the University of Arizona Medical
School, did his residency at the Peter Bent Brigham Hospital of the
Harvard Medical School, and his cardiac training at Stanford.
Deborah is unique in a couple of ways. Founded in 1922 to treat tuberculosis
with the help of pure air of the Pine Barrens, its work now is almost
entirely in cardiac services. The hospital has eight cardiac surgeons,
four perfusion teams, and eight anesthesiologists preforming 1,000
heart operations a year in five operating rooms.
None of those 1,000 patients ever gets a bill. The hospital accepts
payment from insurance companies, but does not bill patients for the
co-pay. If patients are uninsured, and can not pay, they are treated
at no charge.
Deborah does some bypass surgeries on the pump, and some off the pump.
It’s a matter of physician preference, Dennis says.
Patients are moved from the care of their cardiac surgeon to the care
of their cardiologist 24 hours after surgery, a practice, Dennis says,
that provides better overall care.
"What do surgeons want to do?" he asks. "They want to
operate." Better, in his view, to move post-op patients quickly
on to a doctor who will have more interest in — and knowledge
of — the patient’s entire health picture.
In his position as cardiovascular advisor to the state’s Department
of Health, Dennis is in a unique position to comment on which hospitals
should offer which cardiac procedures — and why.
"We’re moving in the direction of deregulation of cardiac services
in New Jersey," he says. "The question is: Do you want access
to these services in every community? Say we put cardiac in all 82
hospitals, no one would be doing enough to drive quality. It’s a three-legged
stool — cost, access, and quality. You can’t have all three."
"Look at St. Francis," he volunteers. "They do high quality
work, but are having trouble making numbers." The state says a
hospital needs to do 350 cardiac surgeries a year to maintain quality.
"In may opinion," says Dennis, "it’s 500. As volume goes
down, we have problems sustaining quality and controlling cost."
(Persichilli, told of this comment, replies in an E-mail, "with
the addition of the second cath lab, we will meet those numbers, but
if we do not, our report card speaks to our quality…volume is really
just a proxy for quality.")
A reason some hospitals are eager to start cardiac programs, says
Dennis, is that they are money makers. "It’s a business decision,"
says Dennis. "There are few things a hospital makes money on.
One of them is cardiac. Profit margins for hospitals are 2.5 percent.
There is an 8 percent profit in the cardiovascular service line."
In hospitals with cardiac programs, Dennis says, it accounts for 40
to 50 percent of volume, 60 to 70 percent of revenue, and most of
the hospital’s profit.
Says Dennis, "Some hospitals say `let’s get into it. We’re losing
our shirt on a lot of other things."
But even as hospitals are seeking certificates of need to perform
heart surgeries, the number of those procedures is going down. "We’ve
seen a significant volume fall off in open heart," says Dennis.
"We’re doing much more in the cath lab. The advances in catheterization
have been huge."
One such advance is brachytherapy. Arteries opened by stents can grow
scar tissue that closes them — sometimes even making the blockage
worse than it was in the first place. In brachytherapy, radioactive
seeds are put at the site of the blockage for three to five minutes.
"I’ve done 100," Dennis says of the procedure. "I did
one yesterday on a lady with a stent. Her artery was 99 percent blocked
off by scar tissue." The procedure got the blood flowing again.
Says Dennis, "she will not be having bypass."
In the fall or early next year, the FDA is expected to approve the
use of drug-coated stents that will keep scar tissue from forming.
While brachytherapy reduces the need to replace a stent because of
scar tissue build up to about seven percent, tests of coated stents
have produced results cardiologists term "amazing" and "revolutionary,"
taking the percentage of scar-tissue-blocked stents down to between
zero and two percent.
The coated stents also turn some bypass candidates into angioplasty
candidates because where, now, a cardiologist often will not attempt
a bypass on a patient with multiple blockages, assuming at least one
will be closed by scar tissue, with the use of coated stents, he can
be confident that all the stents will remain open.
Given fewer bypass procedures, the cost of building a full cardiac
program, and the volume required for quality surgery, Dennis is not
enthusiastic about more hospitals being granted certificates of need
to preform the operations.
But what about angioplasty, the procedure the JAMA article suggested
should be available at every community hospital to treat heart attack
Before addressing the question of angioplasty certification, Dennis
says, "11 years ago, we had 25 cath labs in the state. There will
be more than 70 when all the new cath labs open. Is 70 too many? Probably.
Was 25 too few? Probably. Some people are doing diagnostic cath well,
some are on the borderline. Some were put in for business reasons."
In case of a heart attack, he says, yes, angioplasty has been shown
to get blood flowing to the heart more quickly than the other common
approach — the administration of clot busting drugs, which work
60 to 70 percent of the time. Studies have shown that three to four
more people out of every hundred would live if given angioplasty rather
than the drugs.
"The concern," says Dennis, "is how do you take a lab
and get it up to do angioplasty on the very sickest patients?"
The cath labs in the studies JAMA quoted had received very extensive
training, Dennis says. Angioplasty, he explains, is a procedure that
requires not only an experienced doctor, but also a highly skilled,
experienced team. Team members work closely with the doctor, holding
the guide wire in place while he inserts the catheter, for instance,
and operating complex computer equipment.
"The people in the lab have to be pretty sophisticated," Dennis
says. "The question is: Do we have sufficient manpower in the
state to do primary?"
The most crucial real life decision for Route 1 corridor residents
and workers is where to go if they begin to experience chest pains
or other symptoms of heart attack.
Should a person working in Carnegie Center go to Princeton, which
is the closest hospital, but which does not offer angioplasty, or
to St. Francis, which is a little farther but does offer the procedure?
"Call 911," says Dennis. "EMS is structured to take patients
to the nearest hospital, and that is not a bad idea. A lot of bad
things can happen very fast."
However, he continues, if the state decides heart attack patients
should be taken not to the nearest hospital, but to the nearest hospital
offering angioplasty, "there will have to be a triage system.
Do we drive past one hospital to get to a hospital with primary angioplasty?"
In the meantime, while the Department of Health ponders these issues,
and surgeons debate the best way to perform open heart surgery, Cardello
of Capital says area residents would do well to heed traditional admonitions
issued by moms everywhere and "eat your veggies." While plenty
of disagreement swirls around cardiac services, there is unanimity
on the importance of prevention — smoking cessation, healthy eating,
Debbie Lawrence has been a cardiac nurse for the better part of her
adult life. She led me back to the nurses’ locker room after I had
observed open heart surgery at St. Francis, and was thinking how very
much I would like to avoid ever being on that table.
"Does seeing this every day keep you away from cupcakes?"
I asked her. Indeed it does, she replied.
Corrections or additions?
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