Heart doctors put patients before egos
Luzia Cardoso went home to die. The 70-year-old woman had a four-inch-long crack in the lining of her aorta, the main artery carrying blood to the body, and it was sure to kill her when it burst.
Surgeons at Beth Israel Deaconess Medical Center wanted to put a liner over the crack, but Cardoso's aorta had too many unusual twists and turns to get the liner there without tearing the artery.
Then, surgeons from two specialties that have long competed over who should operate on the aorta realized that they might be able to save Cardoso by working together. In a novel procedure, the heart surgeon would cut a small hole in Cardoso's heart, creating a new pathway to the leaking artery; and then the vascular surgeons -- experts in the repair of arteries -- would insert the liner to stop the blood from escaping.
The team spirit at Beth Israel Deaconess is part of a profound change in the way doctors confront cardiovascular disease, the nation's number one killer. Long a field sharply divided among specialties, the treatment that cardiovascular patients received has often depended on what kind of specialist they went to first. Surgeons were more likely to recommend surgery, while an interventional cardiologist -- trained to prop open blood vessels without major surgery -- would generally suggest the less invasive alternative.
But now, from the $350 million cardiovascular center under construction at Brigham and Women's Hospital to a new floor plan that will bring cardiovascular specialists together at Lahey Clinic in Burlington, old turf lines are rapidly breaking down. Heart and vascular surgeons as well as interventional cardiologists increasingly collaborate on patients, sometimes working side by side in hybrid operating rooms that contain the specialized equipment each needs.
''There's a paradigm shift in medicine. It's no longer about disciplines. It's about diseases," said Cardoso's heart surgeon, Ralph de la Torre, who began teaming up with the hospital's vascular surgery chief, Frank Pomposelli, on complex cases like Cardoso's a year ago. ''It's not a collaboration. It's a merger. We look at it as cardiovascular surgery."
The pressure for change is particularly intense in cities such as Boston, home to numerous highly specialized teaching hospitals including two -- Massachusetts General Hospital and Brigham and Women's -- that rank among the top heart centers in the nation. But greater collaboration is happening everywhere: Tomorrow, national associations of cardiologists and vascular surgeons plan to announce joint guidelines for treating patients with poor circulation to the legs, feet and intestines.
No one expects that closer cooperation will always go smoothly: There's too much pride (''Surgeons are a pain. . . . They all have egos," admitted de la Torre.) and money (more than $60,000 for a single coronary artery bypass) at stake for that. But intense competition for heart patients among hospitals, along with rapid technological changes, are forcing doctors in all three specialties to re-think the way they do their jobs, heart specialists say.
''Cardiologists are thinking more like surgeons and surgeons are thinking more like cardiologists," said Dr. Richard W. Nesto, chairman of cardiovascular medicine at Lahey Clinic.
In another recent example, cardiologists and surgeons at Brigham and Women's in August pulled off a New England first: they repaired a woman's leaking heart valve without surgery. Dr. Andrew Eisenhauer, an interventional cardiologist, instead snaked a catheter from an artery in her groin to her heart, then attached a tiny clip to two flaps in the valve so that they would close snugly. Brigham heart surgeons agreed the new treatment was the 57-year-old patient's best choice.
''We look at patients together and ask, 'Are they better served with one of these [clips], or are they a candidate for surgery?" explained Dr. Campbell Rogers, chief of interventional cardiology at the Brigham, noting that surgery would still be required for more severe cases. ''That's the way it ought to be done for the next 30 years."
The turf lines were much clearer when Dr. Sidney Levitsky got out of medical school in the early 1960s. As a heart surgeon, he was allowed to insert a catheter into the left side of the patient's heart, but not the right. The left was reserved for the cardiologists. Levitsky could operate on the aorta, the main artery leading from the heart -- but only until it reached the diaphragm, a band of muscles beneath the heart. Then the operation became a job for the vascular surgeons.
''It sounds silly today, but that's the way it was done," said Levitsky, a cardiothoracic surgeon at Beth Israel Deaconess and the president of the Society of Thoracic Surgeons.
In the first decades after World War II, he explained, heart surgeons became so busy with coronary artery bypass surgeries that vascular surgery grew up to handle other artery repairs. But it was always an artificial distinction, he said, and the two specialties could never agree on exactly where the heart surgeon's domain ended and the vascular surgeon's began. ''It's my personal feeling that it's time for these two specialties to come back together again," Levitsky said.
At Beth Israel Deaconess, the longstanding friendship between chief cardiac surgeon de la Torre and chief vascular surgeon Pomposelli smoothed the way for the specialties to come together around complicated cases. Equally important was the hospital's decision to split revenues between the two specialties whenever they collaborated. Now, Beth Israel heart surgeons are learning how to insert artery liners, called stents, from vascular surgeons, while the heart surgeons are teaching their colleagues how to work with a heart-lung bypass machine, which circulates a patient's blood while his heart is stopped.
''Eliminating the turf wars allows people to think creatively," said Pomposelli. ''How can we work together to solve an incredibly difficult problem? We think outside the box and do things that we wouldn't do on our own."
That new thinking saved Luzia Cardoso's life.
Earlier this year, Beth Israel cardiac surgeons replaced part of Cardoso's aorta, which had a crack in the interior lining called a dissection. But the dissection was far more extensive than the surgeons realized, and she returned two months later with a swollen aorta that threatened to burst if nothing were done. De la Torre told the woman's family that a second surgery to replace a section of the artery carried a 50 to 75 percent chance of killing her.
And repairing the damaged artery by inserting a liner was out of the question, he felt, because Cardoso's aorta contained two sharp turns where the liner would probably tear through as it was inserted.
''If she had so little chance to survive, it would not be a good idea to go through a second operation," recalled Cardoso's daughter, Tamara Saviatto, and the family took a weary and discouraged Cardoso home for what they thought would be her last months.
But de la Torre, Pomposelli and fellow vascular surgeon Marc Schermerhorn kept thinking about Cardoso' case, finally coming up with the plan to insert the liner, called a stent graft, directly through her heart.
Twelve days after the early-November operation, Cardoso went home. Now, Saviatto said her mother no longer requires oxygen to breath and she can walk with assistance. ''She's doing great. She looks great," said Saviatto.
Scott Allen can be reached at allen@globe.com. 
