Old problem, new tools
Cardiovascular surgeon Pramod Bonde takes an unconventional approach to repairing aneurysms, sparing some patients transplants or implants.
Lucian Capozzo spent a lot of his time in intensive care cracking jokes, and he’s still at it as he sits in the kitchen of his Wallingford home in February. “I need one more hospital stay to get down to 160,” he said—a jibe at his struggle to lose weight. Between the jokes a story emerged about his massive heart attack last year and the surgery and rehabilitation that followed. He finally grew serious when he talked about his children—Frankie, 13, and Marissa Rose, 9—whose pictures decorate the refrigerator, the walls, and every shelf of the family’s home. When doctors told him he’d need a heart transplant, his thoughts flew to them. “Am I going to see them graduate high school?”
Today Capozzo, 48, is back at work, and in his spare time shoots baskets with the kids. He’s planning family trips to Disney World and the Jersey shore and looking forward to more distant milestones, like sending his children off to proms and dancing at their weddings.
Capozzo was in heart failure in early 2013 when he was referred to Pramod Bonde, M.D., assistant professor of surgery, for a left ventricular assist device (LVAD) as a bridge to transplantation. The device keeps the heart pumping until a donor heart becomes available—if the patient is fortunate. More than 10,000 Americans have died since 1995 while waiting for a donor heart.
Instead of an LVAD, Bonde proposed to repair Capozzo’s heart through surgical ventricular restoration (SVR), an operation first performed by Vincent Dor, M.D., in France in the 1980s. Though Bonde regularly performs LVAD procedures and heart transplants, he said that it is important to match the procedure to the patient’s particular need—even if that means doing a relatively uncommon operation.
Bonde is one of only a handful of surgeons in New England who perform SVR, and he might seem an unlikely proponent of the surgery. It relies more on surgical skill than technological support, yet much of Bonde’s work focuses on technology. He is director of mechanical circulatory support in the Department of Surgery at Yale and a frequent collaborator with engineers. His research group has close to a dozen medical, engineering, and undergraduate students and research assistants working on problems that must be overcome before an innovative artificial heart can be made viable for humans. Bonde’s team is also working on designs for an artificial lung, a portable device for producing circulation and oxygenation support outside the hospital, and a mechanical CPR device. They are developing a wireless LVAD instrumentation for minimally invasive cardiac surgery, as well as simulators for teaching surgical techniques. One of the most advanced projects is for a tiny, implantable pump that would switch on only when needed, as a pacemaker does, allowing some patients to be weaned from the device. But Bonde is also a surgeon who, with new techniques and tools at his disposal, likes to think outside the box.
“We believe a creative and imaginative environment is essential to innovation,” says a message to visitors to the lab’s website. “This has been the cornerstone of our approach to solving complex problems in cardiac surgery.”
If his work creating new devices suggests that Bonde is interested primarily in technological solutions, that’s only half of the story. The SVR procedure requires a fair bit of artfulness on the surgeon’s part. Despite extensive imaging, surgeons cannot really see the damage to the heart until they are looking inside the patient’s chest. Knowing where damaged muscle ends and healthy muscle begins is a matter of experience and judgment. “That really is the challenge of the procedure,” explained Bonde.
Adapting the procedure to individual patients is critical to its success. Bonde has seen men and women of various ages benefit from it even though their heart attacks left different kinds of damage. Among his patients was a woman with heart failure whose medical team was discussing withdrawing life support. After an SVR and a bypass operation in November 2013, the woman was able to enjoy the winter holidays with her family—and go out shopping for presents.
Although SVR is now more broadly used to address scarring that contributes to heart failure, the procedure was originally conceived as a strategy to repair ventricular aneurysms like Capozzo’s. His aneurysm—a thinning of the heart wall that makes it vulnerable to rupture—had forced his left ventricle from its natural elongated shape into a life-threatening spherical form. To fix it, Bonde would have to cut away damaged muscle and use a mesh patch to reshape the ventricle. Bonde usually performs this operation in conjunction with CABG, a bypass operation.
This procedure spares patients the many lifestyle adjustments that an LVAD dictates, like bathing restrictions and the need to cart the device and a backup power source everywhere. SVR can also postpone—or make unnecessary—a heart transplant or implantation of an LVAD. Capozzo never had to wait for a donor, worry about immune system rejection, or take immunosuppressive drugs. “This can be a permanent fix for those patients who have been so sick and have lost all hope,” said Bonde.
Indigestion or heart attack?
Capozzo had not paid much attention to the symptoms that first surfaced during a dinner he had hosted for his wife’s family in November 2012. “I blamed it on the extra sausage and peppers.” Capozzo found it impossible to sleep lying down that night. “I felt like I ate fast and the food got stuck somewhere,” he said. Because he never felt pressure on his chest, it didn’t occur to him that he’d had what his doctors later concluded was a massive heart attack.
He spent the following weeks treating with antacids what he still wrote off as indigestion. After a night shift at his job as an IT professional, he sat down to a snack of tuna and potato chips. Again, he had the feeling that he just couldn’t lie down, and again he blamed it on what he had eaten—he may have had his second heart attack.
His sister Louise saw her brother looking sicker by the day. In mid-December she took him to the Yale-New Haven Shoreline Medical Center in Guilford, where an electrocardiogram revealed that his left ventricle was barely pumping. “I’ve never seen so many doctors run toward a patient in my life,” said Capozzo.
“How did you get here?” a physician asked.
His sister had driven him, he answered. How had Capozzo gotten from the car to the emergency room? the doctor asked.
“I walked in,” he said.
“You walked in!”
Discussing the case in his office months later, Bonde pulled up an MRI of Capozzo’s heart before surgery. The heart was misshapen and filling most of the chest cavity. Capozzo had arrived at the Shoreline Medical Center with an ejection fraction—a measurement of the amount of blood the heart pumps with each ventricular contraction—of 8 percent. The normal rate is between 50 and 60 percent.
The immediate plan was for a heart transplant, until Capozzo was referred to Bonde. “I was pretty upbeat about the transplant,” Capozzo remembers. But he was relieved to hear of another option and immediately agreed to SVR. He had the surgery in April 2013.
The procedure should be far more common than it is, according to John Conte, M.D., a professor of surgery and director of mechanical circuitry support at Johns Hopkins, where Bonde learned the procedure. “There are many, many reasons why you don’t want to do an LVAD or transplant. They are expensive therapies. They are therapies that are fraught with complications; and they are therapies that, despite their best intentions, have limited lifespans,” Conte said.
But SVR had gotten bad press from a trial initiated in 2002 that reported that the procedure, often done in conjunction with coronary bypass, conferred no advantage over bypass alone. Conte and Bonde say that the Surgical Treatment for Ischemic Heart Failure (STICH) trial was flawed. Conte points out that low enrollment prompted the National Institutes of Health to extend the search for volunteers to countries that did not determine whether patients were good candidates for SVR and did not perform the operation according to study guidelines. Editorials in medical journals criticized the trial, and studies conducted before and after STICH showed a benefit over bypass alone. Yet the well-publicized study made physicians hesitate to make referrals for SVR—a chilling effect that Conte says has moderated in recent years. SVR is more common in Europe, where surgeons have more experience with the procedure and have achieved good outcomes.
Matching patient and treatment
Since his surgery, Capozzo has had a chance to reflect on the behaviors that contributed to his heart disease. “I did this to myself,” he said. “I smoked, ate bad, never exercised.”
That’s changing. Now he hits the elliptical trainer three or four times a week. He misses his high-salt diet, especially his favorite guilty pleasure, pickle juice. But for the most part, he’s passing up potato chips and heading for the big bowl of fruit he keeps on the kitchen island. He would like to reach out to other patients who are candidates for SVR and talk with them about his experience.
Not every patient referred for transplant is a good candidate for SVR, Bonde stressed. Those most suited for SVR, Bonde said, are patients who need a bypass or valve operation, have scar tissue from a previous heart attack, and have a resulting low ejection fraction. Conte agreed. “It is a great therapy for a small number of patients,” he said. “And it should be done by people who have expertise in that therapy, like Dr. Bonde; people who also have at their disposal the opportunity to do heart transplants and LVAD. It allows you to match the right operation with the right patient.”