The politics of heart surgery

OVER THE PAST' THREE months, Minister for Health Barry Desmond has given an increased allocation of £2 million to the cardiac surgery unit in Dublin's Mater Hospital. The Mater unit is the only one in the country where open-heart surgery can be performed on adult patients. It is under severe pressure, as the demand for surgery far exceeds the unit's ability to provide it. By Mary Raftery

Last year, the Mater performed over 600 open-heart operations. With the additional finance, it will now be possible to perform about 1,100 per year. Cardiac surgeons, however, estiimate that there are as many as 3,000 people every year in need of surgery. The waiting list is enormous and can be up to three years for the less urgent cases.

The root of the pro blem is Ireland's phenomenally high rate of coronary heart disease, the third highest in the world per head of the population. (Northern Ireland has the highest, closely followed by Western Scotland.) The experts estimate that up to 10,000 people under the age of 65 die of heart disease in Ireland every year. Heart

surgery, they say, can be of assistance to between 20% and 30% of them.

There are currently four heart surgeons in Ireland - Professor Eoin O'Malley, Mr Maurice Neligan, Mr Keith Shaw and Mr Freddie Wood. Of these, Professor O'Malley and Mr Shaw are due to retire shortly, and Mr Wood is the only one to have trained in Ireland, having been one of the first graduates of the Irish course.

Because of the pressure on the Mater unit, the surgeons frequently work up to 12 or 14 hours a day in the operating theatre. The Mater has twin theatres, and the surgeons operate a shuttle service between the two. As one patient is being operated on, another is being prepared for surgery in the next theatre, and a further one in the first theatre while the surgeon operates on the second patient.

Cardiac surgeons are not among the big medical earners, due mainly to the fact that the number of operations they perform is limited by the length of time they take - usually about five hours per operation. Two thirds of their patients are eligible for free hosspital care (i.e. they earn less than £12,500 per year), and in respect of these the surgeons receive a straight azaual salary from the State, in the region of £25,000. The remaining one third of patients are covered by VHI, who have set a consultants' fee of between £400 and £500 per patient, which they pay to the surgeon ressponsible. A rough calculation indicates that a heart surgeon expects to earn an average of about £50,000 a year.

The total cost to the State of each operation, including the costs associaa:ed with the elaborate tests which znust be carried out before' it is perrformed, varies between £3,000 and £6,000. The Mater cardiac surgery unit receives State funding of £2 million a year. The coronary artery by-pass is one of the more basic operations; the insertion of an artificial valve costs an extra £1,000, and a pacemaker around £700. It is difficult to estimate the cost of a heart transplant, as none has yet been performed in Ireland. However, by virtue of the additional State funding, the Mater hopes to be in a position to perform the transplant operation by next year.

It takes up to 17 years training to become a qualified heart surgeon - 7 years of basic medical training, 4 years to obtain the general surgeon's qualifiications and a further 6 years of speciaalist training. It has for some years been possible to be fully trained without leaving the country, but all prospective cardiac surgeons are encouraged to undergo part of their education abroad, particularly in the United States, where much of the research work into new surgical techniques is carried out. Six Irish surgeons have so far passed through the course, and there are currrently two doctors being trained, one of them a woman.

tHE ELABORATE BATTERY OF tests on patients suffering from heart disease are carried out by clinical cardiologists, Baggot Street Hospital has the primary testing laboratory in the country, and last year 1,369 patients were investigated in the hospital, an average of 9 a day. At present, patients awaiting testing (and you can be waiting for over a month) must be admitted to hospital for some days and thus take up valuable beds. Cardiologists point out that if they had the administrative and secretarial resources, testing could be carried out on an overnight or even a day-care basis, thus reducing the waiting list and freeing much-needed beds for other purposes. They also complain bitterly about how few of them there are - Ireland has only eight clinical cardiologists (5 in Dublin, 2 in Cork and 1 recently appointed in Galway) compared for example to eighteen in Northern Ireland, where even that number is considered less than adequate.

One of the main investigative proceedures in operation is known as angioocardiography. It involves the injection of a chemical dye into the arteries of the heart through a catheter tube innserted into a vein or artery in the arm. The progression of the dye through the heart arteries is then recorded on 3Smm X-ray film, showing up any blockages which are caused by cholessterol deposits gradually building up within these arteries, and progressively blocking them up so that the flow of blood around the heart is diminished and its pumping functions become consequently less efficient. As the blockages become larger, they are accompanied by chest pain (angina) which occurs particularly during times of stress and exercise, when the heart is required to pump faster but lacks the blood supply to do so efficiently. A heart attack (coronary thrombosis) occurs when the cholesterol deposit has completely blocked off the artery, thus stopping the blood supply.

So far, medical science has not disscovered a way of effectively breaking down the cholesterol blockages. The most commonly performed operation (60% of cases in the Mater) is a coroonary artery by-pass. A vein is removed from the patient's leg (or occasionally his or her chest wall), and is sewn onto the blocked heart artery just before the location of the blockage, and its other end is connected up a short distance beyond the blockage. The blood then flows through the sewnnon leg vein, by-passing the blocked part of the artery. The second most common operation is a valve replaceement; valve damage is most usually caused by rheumatic fever.

The other main area of heart surgery is on small children, for probblems such as a hole in the heart, or the blue baby syndrome. About 120 of these cases arise each year, and last year 107 operations were performed. The centre for child open-heart surgery is Our Lady's Hospital in Crumlin, and the cardiac surgeons attached to it are Mr Neligan and Mr Wood.

One of the most revolutionary new techniques to have been developed in recent years is known as angioplasty. It is used on adult patients suffering from angina, and is a remarkably simple though very delicate procedure. It consists of injecting a tube into the heart and up along the partially blocked artery. At the end of this tube is a small plastic balloon. When the balloon has reached the narrowed, blocked part of the artery, it is inflated, pushhing out the artery walls, and allowing the blood to flow normally.

tHE SUCCESS RATE FROM THIS procedure is high. It does not reequire opening the chest wall or the use of a heart-lung machine, both of which are necessary for the by-pass operation. The recovery rate is extremely fast @the patient can be out of hospital in two days and back to work in a week.

It is, however, only suitable for a relatively small number of patients (about 5%. Patients with several blockkages are still advised to opt for a byypass operation, as the chances of success are higher. The centre for angioplasty in Ireland is in Baggot Street Hospital at the moment. It is performed by three of Dublin's clinical cardiologists - Dr Gerard Gearty, Dr Brian Maurer and Dr Michael Walsh - who have been innvolved with the technique since its introduction to Ireland two years ago. So far, about 70 patients have been treated using angioplasty, and Bagger Street is now applying the procedure to two patients a week. One of the limiting factors on the numbers which can be treated in this way is that the cardiac surgery unit in the ~ater must be on stand-by while they are being performed, as complications can arise which require immediate open-heart surgery. About one in ten of those treated by angioplasty must undergo emergency surgery in the Mater.

The latest and one of the most exciting developments in the surgical battle against heart disease is the disscovery of a new drug, streptokinase, which can be injected into the heart within six hours of what would norrmally be a fatal or near fatal coroonary, and will break down the cholessterol deposit blocking the artery, thus saving the patient's life.

This procedure is not, however, in general use throughout the world, and has not yet been introduced in a routine way to Ireland. Irish and other cardiologists and cardiac surgeons are not as yet convinced of its efficacy, and they await the results of tests which are currently being carried out on the drug in the US and in Europe, particularly Holland. Because of the lack of funds and resources, Irish carrdiologists are unable to carry out such research themselves, and the bulk of research done in this country has been in the preventative area, particularly in the connections between smoking and heart disease.

That research is largely carried out under the aegis of the Irish Heart Foundation, one of whose most promiinent members has been Professor Risteard Mulcahy, a consultant cardioologist attached to St Vincent's Hosspital. He believes firmly in the need for a widespread education campaign in preventative measures which can be taken to avoid heart disease. He beelieves that if the resources are limited, prevention should be accepted as a funding priority as opposed to treattment. "If the £2 million given to the Mater recently," he says, "had been spent on a public health preventative campaign it would be much more beneficial. For the sake of that I would let the odd patient die who might otherwise be saved by surgery."

Cardiologists and cardiac surgeons reply by saying that a disease which kills up to 10,000 people annually, most of them men between 40 and 60 with dependent relatives, must be treated; and that since one of the main treatments is by surgery, the necessary funding must be allocated to it. They emphasise that not only are they in the business of curing people and alleeviating pain, but that they are also putting them back to work. With a success rate of four out of every five patients operated on, and a death rate of only 3.3% after operation, they say they are giving back to the community the productivity of people who would otherwise be unable to work. They also point out the farcically long waitting list. People die waiting for surgery. They even die waiting for their tests. There are so many urgent cases which must be taken, that the less urgent, who may still be in considerable pain, constantly get put back to the end of the queue. The Minister for Health, Barry Desmond, appears to be listening to their arguments. He has indicated that he regards the opening of new cardiac surgery units as a priority. Cork would appear to be ear-marked for the next unit, followed by another in DUblin, possibly in St Vincent's. •