When cardiothoracic surgeon Dr. Sreekumar Subramanian first saw Charles Barnes last November, he knew the odds were stacked against the patient. After suffering a massive heart attack, Barnes' kidneys were shutting down and his heart and lungs were failing. Based on his medical condition, Barnes, who was in a coma, was given a 25 percent chance of survival.
The heart team at the University of Arizona Medical Center and the UA Sarver Heart Center sprang into action and performed "hybrid" surgical procedures tailored to his condition to save his life. Hybrid cardiac surgery combines conventional surgery and catheter-based intervention, with cardiac surgeons and cardiologists working side-by-side to achieve the optimal result for the patient.
The procedure was risky because Barnes – who had several heart attacks starting in 2006 and had previous cardiac bypass surgery – was critically ill with severe lung and kidney dysfunction, and re-operating on a patient who has had previous heart surgery is challenging.
The tailored surgical treatment that gave Barnes a chance at recovery included complicated re-operative off-pump (beating heart) coronary artery bypass grafting, or CABG, which was followed by stenting to help blood flow in an artery that was too diseased for bypass. A stent is a small mesh tube used to treat narrow or weak arteries.
"Re-operative off-pump CABG is technically more complex and requires skilled anesthesiologists. This technique was chosen for Mr. Barnes because of his lung and kidney dysfunction. While minimally invasive heart surgery is an ideal option for some patients, a complex, open-heart surgery was required to save Barnes' life. We chose the redo sternotomy approach because of the condition of his lungs," Subramanian said.
"It's always higher risk than the first time around," Subramanian said. "With that risk of mortality, many surgeons will opt for stenting all the blocked arteries. We elected to go to the operating room because he is young and his best chance for long-term survival was to put an arterial bypass graft onto his main coronary artery."
"We tailored the approach for him," Subramanian said. "We used the internal mammary artery from the inside of the chest wall, which had not been used in the first operation, and that is the best graft material you can use to do bypass surgery. We connected that to his left anterior descending coronary artery."
After Barnes recovered well from that surgery, cardiologist Dr. Ranjith Shetty put a stent in an artery where bypass was not an option.
"It's a good example of a hybrid approach between surgery and cardiology to bring out the benefits of different technology and minimize the impact on the patient," Subramanian said.
The complex surgery was performed without the use of the heart-lung machine, which temporarily takes over for the heart and lungs during surgery.
"Although the heart-lung machine is extremely helpful for most heart operations, with his pre-existing lung and kidney dysfunction, it could have put Barnes at greater risk," Subramanian said.
Barnes was in a coma for almost two weeks of his hospitalization. He was transferred to a rehabilitation facility and now is at home, getting stronger. He is off the ventilator and dialysis.
"There is dramatic improvement in his heart function," Subramanian said. "It shows you what excellent perioperative care we have to help patients through really complex problems using a team approach."
Barnes and his wife of 33 years, Kim, are thankful for that team.
"I would have been dead without surgery," said Barnes, a civilian employee with the Pima County Sheriff's Department. "Now I'm getting stronger. I'm looking forward to puttering around the house. I'm looking forward to enjoying our life."
"Dr. Subramanian was always right there with us," Kim Barnes said. "He is a very wonderful doctor and he cares about his patients. I appreciate all the doctors and nurses. I will never forget them."
Barnes, an Air Force veteran, looks forward to taking walks and bike rides with his wife, and returning to work at the Pima County Sheriff's Department, where he repairs phones.
"It was a miracle," Kim Barnes said. "Dr. Subramanian will always be Dr. Superman to me."