In a procedure thought to be the most radical of its kind, surgeons at the University of Maryland reconstructed part of a woman's diseased heart last week while it sat for five hours in an ice-filled bowl.
The surgeons removed the upper chambers of the woman's heart to eliminate dangerous tumors and fashioned new compartments using tissue from a cow's heart sac. Once reimplanted, the heart began beating normally - giving doctors hope that the woman can lead a normal life.
A handful of procedures of this kind - called autotransplants because the patient's heart is removed and later reimplanted in the chest - have been performed, but doctors have removed a single chamber at most. At Maryland, surgeons removed the left and right atria, which receive blood from the rest of the body and deliver it to the main pumping chambers below, doctors said.
"This was a clean sweep," said Dr. Bartley P. Griffith, chief of cardiac surgery. "We removed half of the heart."
Yesterday, nine days after surgeons sewed the reconstructed organ into her chest, 46-year-old Sandra E. Lanier of Ware, Mass., said she opted for the risky operation because she was weary of having tumors removed that only grew back. Doctors told her that radical procedure stood the best chance of stopping the deadly growths once and for all.
"It was rough but I made it through it," said Lanier at a news conference yesterday, clutching a folded towel to her chest sutures.
Doctors said they hoped the mother of two would be discharged today and would be able to return to working with mentally challenged people in a few months.
"We expect her to make a full functional recovery," said Dr. James S. Gammie who, along with Griffith, led the surgical effort.
Lanier suffered from noncancerous growths called myxomas, which can cause clots and obstruct blood flow through the heart. So far, tumors are the only condition for which autotransplants are performed. And because heart tumors - benign or cancerous - are uncommon, the operations are not likely to be done often.
Gammie had performed two of Lanier's three previous surgeries while practicing at the University of Massachusetts Medical Center in Worcester. In those cases, as well as the third, surgeons removed the tumors while leaving the heart intact.
Recently, when Gammie learned that Lanier had suffered yet another recurrence, he teamed up with Griffith to offer the autotransplant.
"We felt pretty confident we could do this," said Gammie. "And she wouldn't have this sword hanging over her head."
Griffith had performed a successful autotransplant three years ago at the University of Pittsburgh Medical Center on a woman who had a cancerous tumor on her left atrium. In that case, the surgical team removed the left atrium and created one using cow tissue. The patient, an opera singer, has recovered and is in good health, he said.
Transplanting a donated heart was an option in this case, but surgeons feared that the side effects of anti-rejection drugs and the limited durability of a foreign organ might subject Lanier to further suffering.
Despite the use of cow tissue and human aorta, autotransplants do not require the use of immune-suppressing drugs. The cow skin is treated with a chemical that keeps the body from recognizing the tissue as coming from a living thing. Aortic tissue is often treated the same way, though sometimes it is rapidly frozen and thawed to render it safe.
Yet the autotransplant carried risks - the possibility of blood leaking from any of 12 suture lines or of blood clotting in the nooks and crannies of the reconstructed heart. Doctors estimated Lanier faced a 25 percent risk of dying in surgery or shortly thereafter.
Accordingly, they were prepared to place her on a mechanical heart pump and search for a donor organ if the operation failed. Fortunately, their fallback plan was not needed.
Once the heart was removed, Griffith worked on a separate table to create atria from the hide-like tissue of a cow's heart sac. In doing so, he formed the skins into bags and created slits where they would be connected to the lower chambers - called ventricles - and to blood vessels carrying blood into the heart.
Meanwhile, Gammie tended to the patient, creating junctions where the refashioned heart would connect to the patient's blood supply. In one area, he used a section of aorta from a human donor to form the connection between the right atrium and large veins carrying blood from the head and lower body.
"It's kind of like plumbing," Gammie said.
Once they sewed the heart back into the chest and stopped the heart-lung machine, they waited for a tense moment to see if the heart would pump on its own. "It was almost like seeing a new baby born," he said, describing the relief that was felt when the heart kicked into action.
Lanier will have to take blood thinners for the rest of her life because the bags ushering blood into lower chambers do not pump as natural atria do. The blood might pool a bit, creating a dangerous condition for clots to form. If left untreated, clots can trigger fatal strokes.
The hospital with perhaps the most experience performing autotransplants is the Methodist DeBakey Heart Center in Houston. Dr. John Conte, cardiac surgeon at Johns Hopkins Hospital, said he has performed two.
"It's kind of an odd thing," he said. "But the nice thing about the heart-lung machine is that it supports the circulation and you don't need the heart while the patient is on the machine."