TOO BIG A HEART

By DEREK GORDON

There is an expression in Brazil--dar um jeito--that, loosely translated, means no problem is unsolvable and no barrier too great to cross. Dr. Randas Jose Vilela Batista adopted this attitude in dealing with the patients in his tiny rural hospital outside Curitiba, in the south of Brazil. Many of them were dying of congestive heart failure, which caused their hearts to weaken and enlarge. Because he lacked the resources necessary for the standard American treatments for the disease--drug therapy and heart transplant--Batista needed to come up with a different solution. The one he finally adopted appears to be a relatively simple procedure, but it has shaken the world of cardiac surgery and offered new hope to people suffering from congestive heart failure. Batista's radical concept: Since the diseased heart is too big, why not cut off a slice or two and make it smaller?

Batista's procedure could not have come at a more propitious time. Each year congestive heart failure is diagnosed in hundreds of thousands of people. Though doctors are not certain, they believe these patients' hearts were impaired either by damage resulting from a heart attack or by a viral infection. When thus weakened, the heart tries to compensate by stretching its muscles to help it beat. But as the heart's muscular left ventricle expands, it becomes less efficient at pumping blood through the body. Patients in late-stage heart failure pump as little as 15% of the blood that enters the heart back into the body, compared with 65% to 70% for those with a healthy heart. Patients' symptoms include general feelings of weakness and shortness of breath as a result of the poor circulation.

What makes Batista's procedure so revolutionary and so controversial is the seeming paradox of cutting away heart muscle to make the heart stronger. As Batista boldly excises chunks of the heart (some pieces are the size of a normal heart) and sews the heart back together, surgeons around the world are watching with both skepticism and awe.

Neither of the standard therapies for congestive heart failure--drugs and heart transplant--has proved particularly effective. Medications such as ace inhibitors keep the body's blood pressure down, making it easier for a weakened heart to circulate blood, but they do not fix the organ. In late-stage heart failure, the only option is a heart transplant. But while as many as 50,000 people in the U.S. alone need a heart transplant, only 2,500 transplants are performed there each year. Heart transplants have proved quite effective, with mortality rates of only 20% after a year (but 20% to 30% of patients die while waiting for a donor). For those deemed unsuitable for a donor heart--some of the elderly or those with chronic diseases like AIDS or cancer--there is little hope.

The situation is even worse outside the U.S. and Europe. In many countries, heart transplants are virtually nonexistent because of the lack of facilities for performing the procedure. But the facilities are not always the problem. In Japan, for instance, people are not pronounced dead until the heart stops, and then it is too late to donate the organ. (In the U.S., heart donations are possible because death is pronounced when brain activity ceases.) Dr. Torao Tokuda, chairman of the Tokushu-Kai Medical Corp., owner of 40 hospitals and 70 clinics in Japan, plans to spread the Batista procedure to all his facilities. Says one of his top surgeons, Dr. Hisayoshi Suma: "This surgery is of great importance worldwide."

While his operation goes against the general thinking in cardiac surgery, Batista believes he is just respecting nature's laws. He developed his ideas by studying the hearts of animals he found on his horse farm near the Angelina Caron Hospital, where he works. To his astonishment, the heart of every animal he examined, from snake to buffalo, had the exact same proportion of muscle mass to heart size. He found that the relationship came down to a simple equation, loosely based on the law of La Place: mass = 4 x radius3. For every centimeter that it enlarges, the heart needs an enormous amount of muscle mass to compensate. Batista reasoned that since nature had decided on a perfect proportion for hearts, his job was to bring enlarged hearts back to their ideal size. "Is this a miracle?" he asks. "No. We're just creating a more efficient machine."

The conditions under which Batista, 50, operates when he is in Brazil are spartan at best. There is little modern monitoring equipment at his Curitiba hospital. Instead, his technicians are instructed to look for three things: the patient's feet should be pink, to demonstrate adequate blood pressure; there should be urine output, to indicate that the patient has not lost kidney function; and the surgical drain should be clear, to show no internal bleeding. Surgeons depend on large windows in the operating room to provide adequate light for operations.

What keeps Batista going is not fancy equipment but his insatiable desire to find a better way of doing things. He trained in the U.S. and Canada for 12 years, but he discovered on his return to Brazil that he could not count on the state-of-the-art technology he had grown used to. So he had to make do with the available resources. "Established systems don't allow for any creativity," he says. "Here I can ask questions and find new answers. I love challenges." He fills his office walls with inspirational sayings like "He who tries can fail. He who doesn't try, already has" and "Good judgment comes from experience, and experience comes from bad judgment."

Batista's income is as modest as his clinic. He receives about $80 for performing each heart procedure; a doctor in a U.S. hospital would charge about $50,000 to perform the same operation. When he gets paid to talk at a conference, he donates the fee to charity. Foreign surgeons frequently try to wine and dine him at the finest restaurants, but he is happiest chewing corn on the cob at his favorite restaurant, Kentucky Fried Chicken. Batista's chief wish is to set cardiac surgery in a direction that will benefit both the developed and the developing world. "Heart transplants are available to maybe 1% of the world population," he says. "I'm trying to help out the other 99%."

Batista first tried his heart-trimming procedure on a Brazilian patient named Rogerio Luis Mocelim. Mocelim had been suffering from constant exhaustion, and doctors told him of a surgeon who might be able to help. Batista's procedure enabled Mocelim to increase the amount of blood pumped through his body from 15% to 60%. That was three years ago. Today Mocelim drives a truck and regularly plays soccer.

Working in his subpar facilities in Curitiba, Batista becomes discouraged by the U.S. medical system's reluctance to help the sickest patients. "In America," he says, "if a doctor doesn't do anything and the patient dies, it's called a natural death. But if the doctor tries to do something to save that person and he dies, the doctor gets blamed for the death. That's backward thinking." The sickest patients excite Batista most because, he says, "they are the ones I can help the most."

Despite the continuing controversy over Batista's theories and procedures, some American doctors have adopted, and adapted, his work. Chief among them is Dr. Patrick McCarthy of the prestigious Cleveland Clinic Foundation in Ohio, who has done the most extensive testing of the procedure. He has performed close to 60 operations since April 1996. "When I first heard about this procedure, I had to go see it for myself, it sounded so improbable," he says. "But after a few days in Curitiba, we were ready to start trying it out in Cleveland."

McCarthy has been more cautious than Batista and more research oriented. He picks only patients who are healthy enough to be on the transplant list, so that if the procedure does not work they can be put on a left-ventricular assist device, or artificial pump, until a suitable donor can be found. "We've had a 72% success rate with the procedure," says McCarthy. "If you look at all the people who die just waiting for a heart transplant, those odds are pretty good."

American surgeons like McCarthy have brought a level of scientific professionalism to Batista's procedure. To be sure, the greatest benefit of U.S. hospitals is the state-of-the-art postoperative care. American doctors also offer a safety net for patients by placing them on a left-ventricular assist device that helps the heart pump blood into the body if the procedure fails. In addition, McCarthy has somewhat changed the procedure. Where Batista does his work on a beating heart, McCarthy stops the heart so he can make cleaner cuts (a common practice in open-heart surgery in the U.S.). Of greatest benefit is that American surgeons are keeping track of patients, so doctors can figure out the long-term benefits of the procedure.

Others have not been so quick to join Batista's backers. "It's a good idea," says Dr. Lawrence Kohn, a cardiac surgeon at Brigham and Women's Hospital in Boston, "but we're waiting to see the scientific proof." And lack of proof has certainly been a problem. Because many of Batista's patients do not have phones and come from all areas of Brazil, he has done little to track the long-term effects of his procedure. Surgeons in Brazil were no more eager than most American doctors to accept Batista's claims. "When I first heard of this procedure, I thought he was a crank, one of those mystic doctors who periodically appear in Brazil," says Roberto Franken, a Sao Paulo cardiologist who has only recently accepted Batista's procedure. Critics do not bother Batista, though, because he believes so strongly in what he is doing. "Either I'm crazy or they are wrong," he says. "And I know I'm not crazy."

Batista estimates that about 60% of his patients live beyond two years. While many doctors are appalled at such a high mortality rate, Batista counters that his patients are so sick that their mortality rate would be 100% if he did nothing. Many of the patients he operates on would be considered beyond help by American doctors. "I don't have any fatalities," he says. "I only have survivors." McCarthy notes that the uproar over Batista's high mortality rate is reminiscent of the controversy that surrounded the doctors who first started performing heart transplants. Now transplants are considered the state-of-the-art procedure to help heart failure.

Although Batista is best known for his heart-trimming procedure, he is taking his beliefs about size to other areas as well. Eisenmenger syndrome is a disease caused by a septal defect, or hole in the heart. As the condition progresses, fresh and deoxygenated blood begin to mix, with the latter seeping through to the body, causing pressure to build in the lungs and stretching the lung tissue. In the U.S., the defect is usually closed up right away, but in the developing world children often grow up with the hole. Until now, the solution was a heart/lung transplant, which has a high mortality rate. Batista suggests constricting the pulmonary artery to restrict the amount of oxygenated blood flowing back into the lungs, thus enabling the lungs to relax and heal themselves. Again, he believes the body will operate well only if its organs are in proper proportion.

As a medical innovator, Batista is variably described as a madman, a genius--or both. Says Dr. Noedir Stolf, director of the surgical division of the Heart Institute in Sao Paulo: "With his many more ideas for new surgeries, Dr. Batista is likely to keep controversy alive and well in the surgical world for a long time to come."

On a visit to the U.S. to present his findings to leading cardiac surgeons, Batista was rushed off to Baltimore, Md., to see a 32-year-old woman with congestive heart failure who was not expected to survive the weekend. In a moment of reflection, Batista offered a glimpse of what makes him tick: "The big thing for me is that an institution like Johns Hopkins can't do anything for this woman. And here I am, all the way from Brazil, and I have something that may be able to save her." Sadly, the woman was too sick to save. But for millions of others worldwide, Batista's procedure offers hope where before there was none.

--With reporting by Daniela Hart/Rio de Janeiro and Alice Park/New York

With reporting by DANIELA HART/RIO DE JANEIRO AND ALICE PARK/NEW YORK