The Batista Solution
We started by making a “logical” guess that we had waited too long before intervening and the muscle had stretched too much. We assumed that a rebuilding procedure could not improve such an expanded muscle.
Yet that conclusion came from a deduction. It was not an answer.
That’s when I remembered something. My visit to Randas Batista in Brazil blazed into my thoughts, as I recalled how I had been riveted while watching him geometrically return a very large dilated heart back into its natural shape. Until then, our focus was on the heart that became spherical after developing a scar after a heart attack, but Batista addressed the same circular shape that was due instead to a disease in the heart muscle, or secondary stretch from leaky heart valves. The credo of “a circle is a circle is a circle” rang true. Batista simply approached a different disease that also produced the same amount of spherical heart dilation.
As I thought back to what led up to my visit, I recalled that a cardiac surgical colleague, Tomas Salerno, who was Brazilian, had phoned me from his office at the University of Miami to tell me that a surgeon named Randas Batista had achieved phenomenal results after treating heart failure by removing a part of the heart in patients who hadn’t had a heart attack.
Needless to say, I was eager to go to Brazil to meet Batista and learn about what he was doing. Coincidentally, Batista turned out to be the same Brazilian surgeon that Connie’s mother had seen on a TV news program, as mentioned at the beginning of this chapter.
My quest began as I flew to Curitiba in southern Brazil, where Batista worked in a private hospital near the jungle. He described to me how he returned the natural elliptical shape to a dilated ventricle. The method involved removing a wedge of ventricular muscle from its side wall to allow him to reshape the heart as he closed the ventricle. Most operations were done in patients suffering from a chronic heart muscle infection, called Chagas Disease.
This educational experience was uniquely inspiring. I initially watched Batista perform this procedure, then assisted him, and finally did two of the operations with his help. I recognized that this novel procedure that reshaped the heart back to its natural elliptical form was absolutely unheard-of!
And it worked.
Opening the Door on the Dor Procedure
Batista’s success had far reaching implications, since it took a circular heart that had no scar, and rebuilt the natural ventricular shape. This Brazil visit opened a huge door in my thinking, as I now understood why Dor’s method was less effective in very large and dilated ventricles. Instead of only zeroing in on the rebuilding goal of excluding the scar… Batista introduced the core concept of changing the ventricular form back to its natural form. This groundbreaking development refocused me into establishing a new primary objective: to restore an elliptical shape in a dilated heart… independent of what caused its stretching.
This appreciation stimulated my revisiting the ground rules for doing the Dor procedure. That reevaluation was certainly needed, as many other surgeons from around the world had encountered less favorable results after rebuilding very large ventricular chambers. Exclusion of the scar was properly performed, yet the stretched remote muscle stayed stretched. The ventricular chamber was made a bit smaller but remained spherical. The gap in our thinking became apparent, as we had only looked at the scar but failed to see the persistent and detrimental circular shape. (The Batista visit had preceded the RESTORE group formation by several years.)
This newly found vision made me refocus upon the role of simple geometry. For a new breakthrough to emerge, form needed to take center stage. This did not contradict the critical importance of excluding the scar. Instead, it made us begin to understand that in very enlarged ventricles, the scar occupies a relatively small portion of the cardiac wall. Consequently, scar exclusion alone does not substantially change the spherical chamber’s shape.110 Thus, our failure to sufficiently restore the remote muscle’s oblique (slanted) 60° fiber angles — resulted in the limited improvement that consistently followed our performing SVR in very dilated hearts.
The new focus needed to be reshaping the ventricular form — not just addressing the disease (scar) that caused the ventricular stretch. (Figure 4)
Figure 4: Surgical restoration for a failing spherical heart (upper image) after a heart attack. Lower left is treating the scar (disease). Lower right is treating form to rebuild natural ellipse.
This expanded range of thinking made me wonder if we had now fully replicated nature. I looked forward to testing whether bringing the very enlarged ventricular shape back into a normal configuration could deliver widespread positive results. Such a prize would yield the ultimate reward for patients and affirm the benefits of my traveling along the discovery pathway.
The Batista Solution Was Not Consistent
The basic tenet of science is that while ideas stimulate action, their validity only comes from proving they are correct. Reports of Batista’s approach had begun to appear in various medical journals, describing the same excellent outcomes that I had witnessed during my brief visit to Curitiba, in which the seemingly incurable patient became dramatically healthy by reshaping the ventricle.
There was great excitement about this breakthrough among the medical community. Some cardiac surgeons realized they could finally approach the failing dilated heart (where the spherical shape was due to disease in their cardiac muscle rather than from a scar after a heart attack), and began to apply Batista’s technique to very sick heart failure patients.
But results varied greatly, as 50% of patients either did not initially survive or died within the first two years. A powerful adverse response followed. Batista was called “A surgeon from the jungle who did a useless procedure.” No one believed his sensational results, and he was uniformly repudiated.
It got worse when statistical reports tabulated results from many international centers and “certified” the high death rate from the Batista procedure. This account followed traditional medical guidelines in which a statistician provides conclusions after using the algorithms that everyone believes to be essential for determining the meaning of the data. Yet something very powerful is missing: the understanding that “statisticians deal with numbers, but have no knowledge of where these numbers come from.” For example, did they arise from suitably selected patients? Or are they certain the operations were done properly?
Nor did the statisticians comprehend the full medical meaning of their numerical observations. In this case, the dramatic reversal of a terminal disease in 50% of patients would confirm a vital and profound finding. Such a dynamic outcome simply cannot happen “by itself” or by “accident.” Yet the statistician’s never-ending response is, “Show me more patients to see if I can come up with better numbers to sanction this procedure.”
It is this disparity that provides the seeds for my imagined scenario below, in which I respond to this single-minded view of the statistician by saying, “I’d like you to meet my talking bear.”
“A talking what?” this statistical analyst would skeptically reply.
I would take this person to the zoo, and upon arrival, we go to the bear’s cage. The statistician looks through the bars, and so does the bear from his side.
The bear says, “Welcome, Mr. Statistician, I really appreciate your visit.”
Shocked, the statistician exclaims, “Astounding — that is a talking bear!”
“That’s right,” I answer. “How many do you need to see before you believe it?”
This allegory rings true for the terminal heart failure patient, where the Batista procedure allows 50% to recover and live a normal life. Their survival tells an overpowering tale.
Glass Half Full
Looking at those 50% death rate results leads one to ask if a physician is a pessimist or an optimist.
All of the patients operated on were very sick, in NYHA Class IV heart failure — with an expected mortality of nearly 100% within two years. And
yes, while 50% of the patients who received Batista’s procedure died relatively quickly…
…50% did not. They returned to normal.
The medical community’s response — to abandon all consideration of this procedure — could be described as having viewed those results like the half empty glass, pessimistically renouncing his work as having no value. Conversely, appreciating that 50% of these otherwise terminal patients were normal at two years, introduces a potent positivity. It mirrors seeing the very same glass as half full.
That latter brand of optimism is my approach. Yet that doesn’t mean I was completely satisfied. Instead, these results ignited my burning question: “What caused the other 50% of patients to succumb?”
“Was there an inherent problem with the concept behind the operation?” I wondered. “Or with how the operation was performed?”
I then remembered something Batista had said when I visited him. He acknowledged that he was not always successful in these dilated ventricles, and he was not sure why. On the other hand, he noted excellent success occurred in patients with enlarged dilated hearts from valve disease.
Was that the clue?
As I thought about this further, I recognized that conventional thinking (including Batista’s) — was that enlarged ventricles that expanded from a chronic heart muscle infection, occur as that disease is evenly distributed throughout the entire ventricle wall. But what if it were not? What if only part of the ventricle wall was unhealthy? What if sometimes the surgeon — Batista or others — removed a wedge of muscle that was not diseased?
If true, this means that the concept of the operation was correct… but that it was performed on the wrong part of the heart.
This theory made sense to me, since Batista had superb results in valve patients — where no infection was present within the heart’s muscle mass. Because of this, any part of the ventricular wall can be removed as an elliptical form is rebuilt.
I suspected this reasoning could explain why some patients had a better outcome.
Wheels of Progress
But this conclusion was only a deduction. The prevailing question became: could this lead us to develop a better way to treat patients with large ventricles?
Discussion, questioning, brainstorming — are standard activities for everyone from writers and musicians to educators and politicians. Why not for surgeons?
The crucial components include open communication while making sufficient time available to see if such conversation can be productive. This happened in southeastern Italy in 2000. I had attended a heart failure meeting and was returning to Rome by bus with Hisa Suma, a renowned Japanese surgeon who was part of our RESTORE Team. We both lamented that the Dor operation did not always work in very large hearts.
“I have an idea you might find interesting,” I offered.
We were the only passengers on our small bus and for the next two-and-a-half hours, we paid little attention to the exquisite Italian countryside sweeping by our windows, as we discussed possible solutions to these previously unsuccessful treatments.
I brought up what I had learned while visiting Paco, about the helix and the wrap, and that the ventricle must be a V shape in order to function well (which helped explain our overall successes with the Dor procedure). I noted that Paco did not focus on what disease may have caused a distortion — his only concern was the structure that makes the ventricle and heart function properly.
Intrigued, Hisa concurred that, “With the Dor procedure, we concentrate on excluding the scar, to reduce remote muscle stretch and try to return the heart to a normal elliptical shape.”
“That’s right,” I continued, “But what if we do that with very large ventricles?”
Hisa nodded, now understanding my curiosity. “It is less effective because the spherical shape remains, but just a bit smaller.”
I then questioned, “So should we focus less on treating the disease [scar], and more on treating the form itself — by whatever method works best?”
Hisa was intrigued. I offered my solution to how to make this happen in the operating room.
“Instead of attaching one end of the patch at the heart’s apex [the tip at its bottom] and the other up at the top of the scar like we do with the Dor procedure… what if we attach one end of the patch at the apex and the other to a site near the top of the heart? Such a baseline change in strategy…”
“…will not only exclude the scar, but will also reshape even very large ventricles back into a V configuration,” Hisa said, finishing my thought. We looked at one another and realized a new solution was now before us.
We were entering uncharted waters yet again, for nobody had ever done this. Here we were, two cardiac surgeons, from the East and West, seeking novel horizons while our bus wove through picturesque scenery. Yet our excitement magnified as we envisioned a promising new way to improve outcomes in the very dilated hearts of patients who’d had a heart attack.
Bringing Up Batista
Delighted as we were, we both knew our conversation was not over.
We realized this dilemma of impaired heart performance also affects patients whose enlarged ventricles — have no scar. The disease was in their muscle, as they did not suffer a heart attack.
So I cited, “Batista has his unique approach that might work.”
Hisa was familiar with the Batista procedure, and agreed it was an extraordinary operation. Then he noted, “But Gerry, I’m sure you know it only works in about half the cases.”
It was time to reveal my new theory.
“Yes, and we know that Batista and others remove one area of the ventricle to reshape it, believing the underlying disease is evenly distributed [homogenous] throughout the ventricle. But what if it’s not?”
Hisa’s eyes lit up. “That… is fascinating.” I saw his mind working, sorting together pieces of the puzzle as he continued, “If it is only in certain portions — that could explain why procedures are only sometimes successful! If the surgeon elects to remove tissue that happens to be where the disease is — the operation is effective and the patient improves. But if the surgeon removes a healthy portion that has no disease…”
“…then the patient dies,” I said, now finishing his sentence.
Hisa was as captivated by this possibility as I. He contended, “Gerry, we need to discover if such disease is throughout the walls of the entire ventricle, or only in one portion. Most importantly, if only a portion is diseased — we must find a way to locate it — so we only remove the diseased region.”
The two of us were in agreement. We knew we had the right questions. Now we needed to find the right answers.
Guys Talk. But Men Act.
One of my favorite books, by the architect Gyorgy Doczi, is called The Power of Limits.110 It deals with harmony in nature, art, and architecture. Doczi describes “knowledge” as analysis and differentiation — to take apart. He defines “wisdom” to mean integration and synthesis — to put together. Finally, “wholeness” reflects the action taken that will unite knowledge and wisdom.
This exactly describes surgery. Surgeons have to act. They can’t ponder all day long, “What would happen if I did this or did not.” The surgical credo involves taking such action, and this principle stands behind my describing this section as essentially, “talking by boys and actions by men.” Often, you must go out and do something that nobody else has done before.
During our bus journey, Hisa asked further how I learned about the helix and the idea to reshape the ventricle. I told Hisa more about Paco Torrent-Guasp and his being a stupendous resource for revolutionizing our concepts of ventricular form and function. Hisa listened — and subsequently acted — by taking his own trip to Spain to visit Paco. He reported afterward, “You’re right. This is unbelievable!” Hisa came back as impressed as I had been. He and I are dear friends, as we share a world of curiosity — the bridge to translating our ideas into new actions.
Hisa’s concern about the oddly high
death rate that others had witnessed while doing the Batista procedure, led to his next step. Taking a page from Leonardo da Vinci, who inspired us by stating, “First I shall do some experiments before I proceed farther,” Hisa designed a beautiful clinical study to find the answer. (da Vinci’s advice to first conduct experiments had not been followed by those surgeons who tried doing the original Batista procedure). Hisa’s inquisitive nature led him to find out why something happened.
Hisa took small pieces (biopsies) of a diseased ventricle’s lateral wall and septum. What he found was remarkable.
He discovered that the total amount of diseased tissue was about 19%, but that the concentration of this diseased tissue varied in different areas from 4 to 60%! For example, in one-third of cases, it was most pronounced in the lateral wall… yet in another third, it was greatest in the septum.111
The disease was not uniform throughout!
These findings showed that the conventional belief of even distribution of the disease over the entire ventricle was completely wrong.
The ramifications of this knowledge were gigantic because Hisa solved a worldwide question that had confronted many surgeons. It now became clear that the patient might die — if the surgeon unknowingly removed the healthier portion (that maybe had only 5% diseased tissue). Mistakenly “taking the good while leaving the bad” was the unequivocal answer that explained the inconsistent results after the Batista procedure.
The incorrect assumption was that all parts of the ventricle suffered a uniform disease. They did not! The Batista procedure was not faulty. The problem was that it was done on the wrong part of the left ventricle.
This was incredible information. But how to use it?
That led to a critical question that still had to be answered: was there a way to determine (without a biopsy) which area is heavily diseased and needs to be excluded?
Action is the driving force of the surgeon, and Hisa Suma dove in to search for a way to define the answer. His creativity bloomed as he developed an ingenious method to sort out which ventricular area should be excluded.
Solving the Mysteries of Heart Disease Page 37