ames Haneman believes his surgeons
sacrificed his mind in saving his heart.
In 1989, Mr. Haneman had a law practice in New Orleans, earned a six-figure
salary and sat on several important state and federal law committees. Then
he had a heart attack and surgery to bypass blockages in his coronary arteries.
He came through the surgery fine — physically. But since then, Mr. Haneman
says, he has had memory problems and even simple tasks, like writing letters,
elude him. His doctors told him the problems would be only temporary. "They
told me not to make any important decisions for a month," he recalled.
But when he returned to work, he recalled, "I could study something
and not be ready to say it the next day, particularly in the order it had
to be presented." The doctors told him to wait another month.
Frustrated, he turned to self-help tapes and books on memory enhancement.
He tried computer exercises and reading nonfiction. But his problems persisted
and after two years he quit practicing law. "When you can't remember anything,
you can't practice law," he said. "I was doing my clients an injustice."
Though Mr. Haneman is an extreme example, heart surgeons say he is not
alone. Doctors say evidence is mounting that a small but significant number
of bypass patients suffer some degree of cognitive impairment, like memory
and attention deficits and language problems, particularly if they spend
time on heart-lung machines.
These patients are apart from the approximately 2 percent to 5 percent
of patients who suffer strokes after bypass surgery, a procedure 600,000
Americans undergo each year.
It is unknown how many patients suffer the less catastrophic, but nevertheless
debilitating, cognitive problems. Depending on how the problem is defined,
studies suggest that anywhere from 10 percent to 50 percent or more of
bypass patients do poorly on tests of memory, language and spatial orientation
six months after surgery. These changes can persist years after surgery,
and in many cases are probably irreversible.
A significant number of these patients will have recognizable problems
in their day-to-day lives. It is estimated that the total cost of these
problems exceeds $1 billion a year.
In part, experts say, the incidence of the problem is increasing because
older, sicker patients are now being offered bypass operations. In the
early 1980's, the average age of bypass patients was about 58, according
to Dr. John Murkin, director of cardiac anesthesia at the University of
Western Ontario in Canada. Now, it is 66.
"As we operate on older and older patients, because of the accumulated
burden of disease in their blood vessels, we're seeing more neurological
injury," Dr. Murkin said.
In part, experts say, the cognitive impairment itself is the result
of stroke, particularly "ministrokes" that patients can suffer when fatty
material is dislodged from the aorta, the body's largest blood vessel,
when it is clamped in order to shunt blood into a heart-lung machine.
The acts of clamping and unclamping can break the hardened fat coating
the wall of the aorta into tiny pieces, like pliers squeezing an eggshell,
which can then lodge in the brain. "On video it looks like a snowstorm,"
said Denise Barbut, former director of stroke research at the Weill Medical
College of Cornell University, who has used ultrasound to study the flow
of these particles during bypass surgery.
Experts say there are probably several other contributing factors, including
tiny blood clots or bubbles from the heart-lung machine, inadequate blood
flow to the brain during surgery and brain inflammation.
Whatever the cause, the syndrome is so pervasive that heart surgeons
and cardiologists have coined a term for it: pump head. Some even go so
far as to encourage some patients to seek other remedies for their heart
disease.
"A high-functioning 75-year-old who I might normally be very aggressive
about bypassing, I might try to manage medically or with angioplasty,"
said Dr. Richard Fuchs, a cardiologist in private practice in Manhattan,
referring to powerful heart drugs and balloon procedures that open up blocked
arteries without surgery. Other experts say they save this advice for patients
who already have some sort of cognitive impairment.
Some experts say some of the cognitive problems after bypass surgery
may actually result from depression, which for reasons that are unclear
develops in many patients after the surgery.
In any event, the cognitive impairment occurs in a minority of patients.
"I have a fairly large cadre of patients who tell me they've never been
better," said Dr. Jeffrey Gold, chairman of cardiothoracic surgery at the
Albert Einstein College of Medicine and Montefiore Medical Center in the
Bronx. "Many will tell you they're much more creative and prolific, that
they haven't suffered any cognitive decline whatsoever."
Dr. Gold points out that some research shows that knee-replacement surgery
can result in similar cognitive impairment and that bypass surgery done
off a heart-lung pump results in stroke rates similar to those when conventional
bypass surgery is done on pump. "I think pump head is a misnomer," he said.
"The implication is that the cognitive decline is due to the pump, and
that if you avoid it you're safe, but that doesn't appear to be the case."
When patients have cognitive changes after surgery, the effects are
often subtle. They may think a little slower or feel "clouded." They may
forget appointments or where they put things. They may become irritable
or depressed.
"The defects can be subtle and patients can often compensate for them,"
said Dr. Mehmet Oz, a professor of cardiothoracic surgery at Columbia-Presbyterian
Medical Center in Manhattan. "On the other hand, if their functioning is
already low, the results can be debilitating."
Sometimes the changes can be a bit bizarre. "Suddenly the type of food
or the type of restaurant they like changes," said Dr. Mani Subramanian,
chief of cardiothoracic surgery at Lenox Hill Hospital in Manhattan. Dr.
Gold of Montefiore said one of his patients recently had called after bypass
surgery to say he was feeling well and was back at work. "But he told me,
`I can't stand the taste of lettuce anymore.' He used to eat a lot of salad,
but that changed after surgery."
For Paul Wechsler, a 60-year-old former architect who lives in New Jersey,
the changes were not subtle or bizarre, just painful. "The bypass surgery
knocked out a lot of my memory," he said from his home, where he spends
most of his days. "It changed my whole life around mentally."
The memory problems started immediately after his bypass surgery in
1996. He told his doctor about them, and was assured they would be temporary.
But in the following months he did not improve. He found himself asking
his fiancée to calculate the tip at restaurants. "I couldn't understand
jokes that she would tell me," he said. "Even now, she'll say something
to me and I'll say, `What do you mean by that?' "
He had been running his own construction business and working as a salesman
before the surgery, but he had to quit. "I used to enjoy the challenge
of building things up from nothing," he said, but it gave him fits. Though
he believes his mental functioning may now be starting to improve, he remains
on permanent disability. "I still have to read a paragraph three times
to get the meaning," he said.
To avoid the potentially deleterious effects of heart-lung machines,
surgeons have developed off-pump, or beating-heart, bypass surgery. Here,
surgeons insert a clamp through a small incision in the chest wall to immobilize
a small section of the beating heart. A new vessel is then stitched, while
the heart continues to pump blood to the brain and the rest of the body.
Aortic clamping and a heart-lung machine can be avoided. The surgery is
relatively new, however, and most bypass surgery is still done on pump.
But studies of whether off-pump surgery protects against pump head have
not produced clear results. Dr. Oz of Columbia is now conducting a study,
the largest to date, in which 600 bypass patients will be randomly treated
with on- or off-pump surgery and studied for cognitive decline. "If we're
going to make decisions affecting the lives of 600,000 people a year, we
don't want to base that on the results of a small trial," he said.
Other treatments for pump head are being developed. Embolex,
a Northern California company founded by Dr. Barbut, the neurologist, has
designed a filter to catch debris from the aorta during surgery. Another
company, Cardeon, has developed a balloon device that opens up inside
the aorta during surgery, shutting off blood flow and obviating the need
for a clamp.
Some experts believe that more attention is being paid to pump head
today because more catastrophic results, like strokes and deaths, have
sharply decreased as anesthesia and surgical techniques have improved.
The mortality rate for bypass surgery is now less than 1 percent. "The
nice thing is that today we can worry about the subtle changes," said Dr.
Mark Newman, chairman of anesthesiology at Duke University Medical Center.
Dr. Gold of Montefiore said the decision about whether to perform bypass
surgery on or off pump can be made in the operating room. He recently had
a 52-year-old patient who expressed concern before surgery about intellectual
decline. After opening up the patient's chest in the operating room and
discovering by ultrasound that his aorta was lined with a large amount
of plaque, Dr. Gold decided to do the bypass surgery off pump.
"The most important thing, in my humble opinion, is to be flexible,"
Dr. Gold said. "The goal is to fit to the patient's needs, not artificially
choose a surgical modality." He added that for the majority of patients,
on-pump surgery — the most studied — was their best option.
Copyright
2000 The New York Times Company
