Beat by Beat

Thanks to stents and better medicine, heart surgeons aren’t cutting open patients with blocked arteries as often as they used to, but they are replacing more aortas and valves. Dr. Art Coffey at IU Health Methodist performs one of these procedures about every 48 hours.

Todd Lewis’s procedure began at 6:45 a.m. on one of the dog days of summer. The 46-year-old Carmelite should have been playing golf, or mowing his lawn, or climbing ladders at his construction job, but he couldn’t do those things without getting winded. He’d gotten used to tiring easily and his wife commenting on his persistent cough, but he suspected something was wrong when he could no longer lie flat comfortably. One day, he felt like he had bronchitis, so he drove himself to an emergency room, figuring the doctors would drain fluid from his lungs and he would go home. Instead, they admitted him to the ICU and removed so much liquid that Lewis lost 25 pounds over four days.

Five weeks later, Lewis is on Coffey’s operating table, too young and fit to have this “disease of the aged,” as the surgeon calls it, but born with a bad valve. The anesthesiologist, Dr. David Stark, soothes him as he goes to sleep, rubbing his shoulders while calling him “buddy” and explaining every touch—the needle in his wrist, the soapy water on his forehead. “Best Day of My Life” plays faintly on a radio. “Nice deep breaths,” Stark says. “We’ll take good care of you and see you in a bit.”

Lewis will miss the rest. A nurse called a “circulator” plasters his body with what looks like yellow Saran Wrap—sticky plastic coated with an antiseptic. By the time Coffey arrives, his team of seven surrounds the table. The physician’s assistant is showing a resident how to palm scissors and flip them in and out of service. Another counts instruments to make sure none go missing.

Coffey opens Lewis’s chest swiftly. The sternum, though incredibly strong, is easier to cut than you’d think. Blood does not gush; it’s suctioned out to give Coffee a clear view of the heart. “The aorta is coming out,” he says. Coffey knew from pre-op scans that Lewis might need a new artery and not just a valve, but he wasn’t sure until he saw it.
The switch-up doesn’t throw Coffey at all. The Indianapolis native trained with the best, including Dr. Harold Halbrook, who performed the country’s first heart transplant at a private hospital—Methodist—in 1982. Halbrook was a family acquaintance and let Coffey observe a heart surgery when he was in college. Coffey has spent his entire career at the same hospital as his mentors, now as IU Health Physicians’ director of the cardiovascular strategic service line.

Coffey prepares Lewis to go on bypass. Soon, tangled, blood-filled tubes snake out of the patient’s chest, like the computer cords behind your desk at home. Potassium chloride stops the heart, as it does in the final stage of lethal injection. The team is still and quiet while Lewis’s heartbeat slows. “This is the coolest thing we do in medicine,” anesthesiologist Stark whispers.

The first surgeon who replaced an aorta used his wife’s panties.

Once Lewis has flatlined, the team moves quickly yet calmly. The less time Lewis is on bypass, the better. They remove calcium deposits around the bad valve, a build-up that looks like cottage cheese. The new valve is a white hard-plastic ring, like a soda-bottle cap open on both ends, with two carbon flaps inside that regulate blood flow. Coffey chose this durable mechanical valve over a tissue version because it will last the rest of Lewis’s life. Older patients will usually receive a tissue valve, which has the upside of not requiring a blood thinner, a common medication that would worsen a stroke if the patient suffered one later. Young women have a tough choice to make: A mechanical valve means they can’t have children, because the medicine it requires taking carries a high risk of birth defects. Some of Coffey’s patients choose the tissue valve so they can have kids, knowing it will have to be replaced down the road.

While Coffey finds the right size, a visiting surgeon from China enters the room to observe. Coffey likes the company he has at a teaching hospital. At a private facility, the team would include just him, the anesthesiologist, and one assistant. Having a crowd was a comfort last year when Coffey was called in on Christmas night, right in the middle of making his green-bean casserole. “We had the music turned up. It was a lot of fun,” he says.

The replacement aorta looks like a small, accordioned vacuum tube. Coffey remembers when surgeons had to make their own replacements by soaking a synthetic cloth in blood and baking it so the blood clotted into the material. He says the first surgeon who replaced an aorta used his wife’s panties. Now companies make synthetic aortas infused with biological matter that prevents leaks, and body tissue grows over it.

Sewing in the parts takes about an hour, then the team starts to bring Lewis off bypass. Some bodies take longer than others to respond. There’s little for Coffey to do but closely monitor Lewis’s stats. An hour ticks by, and Lewis is still reliant on the machine. “You have to be patient to be a heart surgeon. That’s a challenge for most of us,” Coffey says. Conversation with the team turns personal: elk burgers at Bub’s Cafe, chili recipes, weekend plans. Someone asks Coffey about Hoosiers’ health from his vantage point. “In Indiana, we smoke too much,” he says, keeping his eyes glued to Lewis’s still heart. “The percentage of women who smoke while pregnant is higher than the percentage of people who smoke in the country. I always tell patients to stop smoking and offer to take their cigarettes. Only one person has given them to me. They all want one more.”

Eventually Lewis’s body warms up and comes off bypass. His heart is visibly smaller, already working more efficiently. Coffey sews Lewis’s sternum back together with a curved needle that easily goes through the bone, and he leaves a pair of scissors attached to each wire. At the end, he grabs all seven pairs dangling off Lewis’s chest and cuts each line, then twists the ends together and tucks them under. His assistants close Lewis up.

The next time Coffey and Lewis see each other, the patient can’t believe the difference. He had put off going to the doctor because he had been afraid of what his chronic fatigue meant. “Now I feel at least 10 years younger,” he says. “Better than I did in my mid-30s.”