University of Maryland Heart Center cardiac surgeons Bartley Griffith and James Gammie performed an unprecedented operation on August 19 by completely removing a patients heart and reconstructing both of its upper chambers (the left and right atria) with cow and human tissue to save the life of a woman with a rare, recurring heart tumor. Patient Sandra Lanier's heart was removed from her chest for 5 ½ hours during the 12-hour operation before being successfully reimplanted with the rebuilt atria.
A news conference announcing this state-of-the-art surgery was held on August 28. Below are Drs. Griffith and Gammie's answers to reporters' questions about the procedure and its potential impact on the way this and other heart-related problems may be treated in the future.
How radical was this procedure?
Dr. Gammie: It doesn't get much more radical than this. Dr. Griffith took out as much of the heart as he could and still have a heart that pumps.
Dr. Griffith: I think the interesting part about this is that there are a lot of patients with heart cancers that we have frankly given up on or have been unsuccessful with treating even with aggressive removal of tissue. That spawned an interest in removing patients' hearts and doing work in areas where you couldn't quite get to it while the heart was still in place, and there have been a couple of notations in the literature where that has been done. The problem has been not enough, likely, was done with those hearts, to free all of the potential cancer deriving tissue. This was a clean sweep. We basically removed one half of the whole heart, the upper chambers of the heart. And that I don't think we would have been prepared to do if we hadn't gotten away with it about three years ago removing a quarter of the heart, meaning one full upper chamber.
And we're pleased that using a combination of animal parts -- and that's what's truly different about this operation and why it's novel; it was reconstructed using a combination of tissue extracted from cow, or bovine tissue, and human donor tissue to recreate the upper chambers. And they're not normal in any sense; they are serving the purpose of receptacle of blood from the body and from the lungs. They don't contract normally, but they do give the heart the ability to receive the venous blood from the lungs and the body, which is primarily what we removed does. The risk of this thing is you get it all taken apart and you can't get it back together. Or when you do get it back together things don't quite fit right, you have kinks, things of that nature.
What do you expect the patient's future to be like?
Dr. Gammie: We told her that we would expect a full, functional recovery, and that she should be able to lead a normal life. She works with mentally challenged children, and she enjoys her job and we fully anticipate she'll get back to work within a few months.
Did the surgery present any challenges you didn't expect?
Dr. Griffith: In terms of the back table [where the reconstruction took place], the recurrent tumor was more so at the root of the upper chambers, where they evolve from the lower chambers, and that presented more of an aggressive approach than I had planned. It got us right to what I call the newbies of the heart, where we're right on the top of the pumping chambers, and that's a very fragile portion, so I didn't know frankly whether we were going to be able to enough purchase for our tissue to stitch and have it hold. Fortunately it did.
What's the significance of this operation?
Dr. Griffith: I do hope that some patients who have bad malignancies, that either evolved from the heart or go to the heart, might be approached with this type of [treatment]. I think we've done a lot in the past to try to rid heart tumors, but maybe this is just that little bit more, that little bit more radical. So we're hopeful that other patients who have either this disease or cancer of the heart will at least take a look at this potential option, and that our colleagues will view this operation with some sense of guarded enthusiasm and might also develop an interest in it and provide it as an option.
Could this be an alternative for someone who needs a heart transplant?
Dr. Gammie: There have been a few heart transplants for tumors; the downside to that is that getting a new heart requires immunosuppressive regimen long-term for life, and survival would probably not be as good as keeping your own heart. It's always better to keep your own heart. So, yes, I think it does provide a new option for the few patients that have extensive tumors.
What are the chances her tumor will recur?
Dr. Gammie: She faces a very small risk of recurrence, which we estimate at about 5 to 10 percent, were it to come back in the main, muscular part of the heart. But the biology of her tumors has been such that they've always come back in the upper chambers of her heart. She no longer has those, so we feel pretty good that she's not likely to have [a recurrence].
What were the main risks of this surgery?
Dr. Gammie: Anytime someone is on a heart-lung machine for as long as
she was (about 5 1/2 hours), there are complications that can arise from that.
Certainly in the acute phase we were very concerned about bleeding. We had about
14 extensive suture lines and every single stitch had to be perfect. Then there
was the configuration of the new heart, the new atria, the bloodflow through
those, we were concerned about obstructive issues, so all those things, plus
all the usual standard risks.
This was the third open-heart procedure [Dr. Gammie performed] on Sandy. Talk about your relationship with her.
Dr. Gammie: Sandy's a good person. As heart surgeons we usually meet people, operate on them and know them for a few weeks and that's it. So we don't have the long-term continuity. So certainly knowing her for a long time was almost like seeing an old friend again, so that was really special for me.
Do you see applications of this surgery being used to treat other problems?
Dr. Griffith: There are a lot of patients who develop sarcomas of the heart, that are located in the upper chambers, and tend to grow out toward the pulmonary veins. I think this is a good approach to consider as potential therapy for those patients. In terms of [the condition Ms. Lanier has, known as the Carney Complex], there are a limited number of patients who have that [about 400 worldwide], but I would think if I had Carney and had one or two recurrences and if this goes on to be a good outcome for this patient, it could be something that might become a standard of care.