The room is large and bright. A dozen people in hospital scrubs move about, gathering themselves to carry the healing craft of heart surgery another step forward. Dr. Glenn J.R. Whitman, chief surgeon, is one of the first in. He's chatty, eager to begin.

The patient is 56-year-old Dave Nally, an industrial welder from Sharpsburg. He has blockages in two arteries. He has been prepped since 8: 35 a.m. for cardiac bypass surgery at the University of Maryland Medical Center. It is now almost 9. He is anesthetized. And a good thing, too.

He is rolled and kneaded, shaved and probed. He is stuck with needles. Black plastic tubing emerges from his mouth; gray plastic tubing circles his thick right arm. His legs are hoisted into stirrups. A nurse paints his body with iodine and wraps him in plastic; it adheres to his skin like a shrink wrap.

A heart-lung machine stands nearby, but it won't be used. It is only a precaution. Today's procedure will be "off pump," that is, without the machine that cardiac surgeons have relied upon for more than 30 years to do the work of the heart while the repair is made. The machine allows the heart to be brought to a dead-stop so it is not moving as surgeons work on it.

But Nally's heart will continue to pump while the two bypasses are sewn into place.

"This," says Whitman, "is the new frontier of cardiac surgery."

It is a procedure virtually unthought of just over a decade ago, and some think it may divide the medical community generationally, with young surgeons taking to it more readily than their seniors. At least Whitman believes it will. He was hired in December as the hospital's new head of cardiothoracic surgery. His mission is to make the University of Maryland Medical Center the place to go to for off-pump bypass heart surgery.

The hospital averages about a thousand heart bypass operations a year. Before Whitman arrived Dec. 7, only five had been performed off-pump. Since then there have been more than 30, two-thirds by Whitman.

Proponents say off-pump is easier on the patients, but operating on the beating heart presents a challenge to cardiac surgeons.

"When you do an operation on a blood vessel off-pump, you stop the blood from going through the vessel while you do your connection of the new vessel," Whitman explains. "During that period of time we are actually stimulating the onset of a heart attack. The blood isn't flowing. We have five to 10 minutes."

If something goes awry while this is happening -- say an arrhythmia develops, or the heart ceases to pump -- the surgeon must quickly put the patient on the machine.

Glenn Whitman had been a cardiac surgeon for nine years when he turned his attention to the new method he now champions. "We all heard about it. We started to hear about it in meetings in connection with the minimally invasive surgery."

He came to the University of Maryland Hospital from the Medical College of Pennsylvania in Philadelphia, where he headed cardiothoracic surgery. He is a lean man with a narrow face.

Whitman likes to emphasize that off-pump surgery is less a new procedure than a return to the way things were done years ago. "There had been heart surgery long before there was a pump," he says.

Yes, but not much of it, and usually unsuccessful. And even then most surgery was performed on infants with congenital heart defects, such as the famous blue babies. These children are born with holes in their hearts and muscular blockages that inhibit the flow of red oxygenated blood to the lungs, an absence of which lends a blue tint to their complexions.

Also there were occasional surgical attempts to pluck shrapnel from the beating hearts of veterans.

"The mortality rate was very high in this," said Dr. Vincent L. Gott, former chief of cardiac surgery at Johns Hopkins Hospital.

The era of widespread open-heart and bypass surgery began with the invention of a machine by the University of Pennsylvania's Dr. John Gibbon in 1955. This machine, "big as a Volkswagen," sought to keep oxygenated blood flowing to the brain and lungs. It was not entirely successful, but it led to more efficient machines, and ultimately to the heart-lung machine used today, which pumps the patient's blood out of the body and back in again, delivering oxygen to the lungs and brain.

This machine, to Gott's mind, "is still the best thing there is. The success rate is around 99 percent."

Then what is gained by operating on a beating heart? Why is it better than using the heart-lung machine?

Because, Whitman says, the machine is bad for you.

"Complications are multiplied by the time on the pump," he says. "Having your blood passed through a plastic tube is not good for you. God didn't make our blood to go through a pump."

Among those complications Whitman counts the occasional swelling of the brain, infections, the need for transfusions, arrhythmia, stress on the kidneys and, occasionally, blood vessel damage caused when inserting the tubes that lead to and from the heart-lung machine.

Surgeons have been aware for years of these side-effects. Dr. Guy McKhann, professor of neurology at Johns Hopkins Medical School and director of the Kreiger Mind-Brain Institute, is conducting a comparison study of the neurological consequences of coronary bypasses among three groups of patients: those who went on the heart-lung machine, those operated on off-pump, and those who avoided invasive surgery entirely, usually through the gentler procedure called angioplasty.

Though McKhann's data is incomplete, he did say that among those who went on the machine, "a small subgroup just don't get better. Their thinking is slow. Some have trouble planning complex acts. Some are more irritable."

Whitman says off-pump surgery allows for more rapid recovery, quicker exit from the hospital. This means it's less expensive: An on-pump bypass at the University of Maryland Medical Center costs $20,000; off-pump it's about $12,000.

Also, the operations themselves are shorter.

"You do away with the mechanics of going on and going off bypass," says Whitman. "And when you don't stop the heart, you don't have to get it started again, which can take time."

Off-pump is not for everybody, Whitman says: "It is usually successful when the arteries to be worked on are readily accessible. Many vessels are deep in the heart, too imbedded in fat and tissue to do it off the pump; 60 percent to 70 percent of the time you have to use the machine."

There are some for whom off-pump is the only option: people who can't tolerate the stress imposed on the body by the heart-lung machine, elderly patients with weak kidneys.

When it first began gaining acceptance, off-pump surgery was thought useful only when one heart artery had to be fixed, usually the left anterior descending artery, which is the most accessible. To work on arteries deep in the heart, or behind it, the heart lung machine was needed; the heart had to be brought to a dead stop.

But things change.

"We always thought we could never do it around the back of the heart," said Whitman. "But now we can."

Change was encouraged by the growing realization of the damage the machine can do to a minority of patients, and enabled by the developments of new surgical devices.

On Jan. 28, Whitman accomplished the first off-pump quadruple bypass operation of his career: He repaired four blocked arteries. It took him three hours. When he finished he seemed weary, and exhilarated.

Not everyone is the spirited advocate for this procedure that Whitman is. Gott, for instance, has little sympathy for the suspicion of the heart/lung machine expressed by Whitman and others.

"Most of us don't think the machine is harmful," he says, though he adds: "There are, of course, some advantages to off pump."

Dr. John V. Conte, who does off-pump surgery at Hopkins, concedes the machine has inimical effects on patients, but he says it "has stood the test of time" and wonders if "the new operations have results as good as those on the machine. Will the stitches be as good? Is it as good as some say?"

Everything is ready. Whitman's plan for Dave Nally is to use a large vessel, the mammary artery that falls down from the neck past the heart to feed blood into the groin area. This will be cut and the upper portion attached to the left anterior descending artery. This will bypass the blockage in that artery.

For the second bypass, Whitman will remove the radial artery from Nally's left forearm, then connect it between Nally's aorta to his right coronary artery on the bottom of the heart, which is also blocked.

Whitman begins on the left arm, and small puffs of smoke rise as he cuts through the tissue with an electric cautery, which sears the tissue as it cuts to minimize bleeding. He makes the initial cut of the outer skin with a standard scalpel.

As Whitman works into the arm, Dr. Kenneth Saum, chief resident of thoracic surgery, slices through Nally's chest to the sternum, or breast plate. Then he inserts the electric saw and opens the chest. He deploys a steel retractor to spread the chest cavity open about four inches. A nurse draws out the blood rushing into the cavity with a suction, which sends it to a container a few feet away. The blood will be washed, any bone particles removed. It will be returned to the patient after the operation.

Saum moves sponges in and out of the cavity, highly absorbent pieces of white cotton cloth. He then applies a new retractor to open the cavity to about six inches and raise the left side of the chest higher than the right. This gives him more room to work inside. When he has freed the mammary artery from its bed of tissue and fat beneath the wall of the chest, he cuts it and clamps the upper portion to prevent a spurt of arterial blood.

Saum then exposes the sac that encases the heart, the pericardium, which keeps it lubricated and slightly protected. He cuts through this, and the heart, an object the color of a richly veined old cue ball, presents itself. It is a large, vigorously beating muscle, and its emphatic ivory color contrasts excitingly with the rich red of the lungs, moving up and over it, then receding. Saum slides his hand delicately down under the heart. He turns it slightly to locate the left anterior descending artery.

Then he puts a new sponge in the cavity, covers the opening with a blue cloth, and waits.

Meanwhile, Whitman is working to separate the radial artery from its bed of tissue, veins and nerves in the left forearm. It is taking longer than expected. "There was a nerve to avoid," he explained later.

"We're almost there everyone," he says as he teases the artery free and continues his patter. "Arteries are much better than veins. It is an hour of pain in exchange for 15 years of duration of the bypass."

Then the artery is out of Nally's arm. It looks like a worm pulled from the ground on a wet morning. The gaping arm wound is washed then sewn and reinforced with metal staples.

"We could have taken a vein out in five minutes," Whitman explains. "The reason we didn't is because this is a 56-year-old gentleman, and because he needs something that will last a long time." Arteries used in bypasses remain open longer than veins.

The human body is a machine with a great variety of useful redundancies, that is built-in spare parts, explains Dr. Timothy Gilbert, the anesthesiologist on the operation. He monitors the patient's vital signs -- blood pressure, signs of sensation, muscle relaxation -- and feeds in appropriate drugs to maintain a general stability.

The blood delivered by the now lost radial artery in the patient's left arm will be supplied by another artery, Gilbert explains, just as the blood the mammary artery carried to the groin area will be delivered by other vessels put in place by nature.

Whitman is now over the chest cavity and Saum has moved to the left side of the patient. Both physicians work with scalpels to bring the mammary artery into shape. It looks to the naked eye like a formless piece of tissue, rather than as a useful tube for carrying oxygenated blood. But the surgeons see deeper. They are equipped with loupes that provide a three-and-a-half power magnification. Finally the "octopus" is brought out.

This is one of the instruments that has facilitated off-pump surgery. The Octopus Tissue Stablization Device is a two-pronged tool that resembles a carving fork with blunted plastic tines. Four small suction cups are arrayed under each tine, as on the tentacles of an octopus.

Whitman places it on the heart, with the section that needs to be stabilized and worked on, between the tines. Its suction grips and lifts the heart and stills the critical area.

At first the heart hangs there, beating beneath the tines, then there is a squealing, the sound of air escaping. One of the cups is not holding. Whitman doesn't like it. He repositions the octopus. It holds, but then starts squealing again, on the right side where the heart slopes away. It stops again, restarts, then stops. Whitman seems satisfied: "Let's do it."

He makes an incision on the top of the heart and blood pours forth. A nurse squirts saline solution in to wash it away. She uses another instrument to blow oxygen into the incision as Whitman works with his curved needle sewing loops of thread between the lip of the mammary artery and the left anterior descending artery a millimeter below the surface of the heart. A geyser of blood sprinkles the gloved hands flitting like birds in the chest cavity.

All the while the white heart beats, rises and falls like a trapped animal determined to escape. Then the suturing is pulled tight; the bleeding stops. The first bypass is complete. Whitman moves on to the next.

Dave Nally went home four days later; it would have been three but his wife was not comfortable with the idea of driving all the way to Sharpsburg at night, so he stayed an extra day."

Had he gone on the machine, Whitman thinks he would have been in the hospital a day and a half to two days longer than he was.

Telephoned at his home in Sharpsburg, Nally said he was feeling fine "but bored to death."

Pub Date: 4/12/99