"A Cut to the Heart"

PBS Airdate: April 8, 1997
Go to the companion Web site

ANNOUNCER: Tonight on NOVA, a revolutionary strategy in heart surgery.

DR. GIANNI ANGELINI: This is the best thing in cardiac surgery in the last thirty years. And you slash the heart as you could cut across an apple.

DR. PATRICK McCARTHY: The first time I heard about it, I think I probably rolled my eyes and I said, "Yeah, right."

ANNOUNCER: But can this technique save lives? Cut to the Heart.

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WILL LYMAN: The human heart is a magnificent machine. In a single year, it beats more than thirty million times. But when the pump breaks down, misery follows.

LINDA ADAMS: I haven't been able to do very much of anything. Tired all the time, and short of breath.

WILL LYMAN: Two million Americans suffer from a condition known as congestive heart failure. Their weakened hearts simply cannot push out enough blood. And gradually, the victims lose all their strength.

BILL SANOWSKI: Little by little, I couldn't do the work I was doing. So I slowed down and slowed down, and they couldn't do a heck of a lot about it.

WILL LYMAN: When medicines don't help, the only hope may be a heart transplant. But less than twenty-five hundred donor organs are available each year, leaving thousands of patients desperate for a new treatment. Now, a cowboy from Brazil claims to have the answer. Randas Batista owns and operates a cattle ranch here at the edge of the jungle. He is also a heart surgeon. Dr. Batista has come up with a radical therapy for a common type of congestive heart failure, for people with severely enlarged hearts. His idea is simple. Take a heart that's too big and surgically make it smaller.

DR. RANDAS BATISTA: If you have a basketball, if you want to decrease the size of that ball down to a soccer ball, you have to take a slice of it and then sew it back, then it will decrease the size of the ball. So, basically, that's what we do to the heart, taking a slice of the heart and sewing it back, the heart will be smaller. And being smaller, it will be stronger.

WILL LYMAN: In a two year period, Batista performed the surgery on over two hundred patients in Brazil, and he's convinced that it works. But could he sell his idea to the American medical establishment?

DR. RANDALL STARLING: My initial response was, this is crazy, this is ridiculous. You can't cut out a piece of a patient's heart and improve it.

DR. PATRICK McCARTHY: The first time I heard about it, I think I probably rolled my eyes and I was skeptical and I said, "Yeah, right."

WILL LYMAN: Ignoring the skepticism, Dr. Batista contacted heart specialists from around the world, sending them videos of his surgery. One of the first to pay attention was Dr. Gianni Angelini of the Bristol Royal Infirmary in England.

DR. GIANNI ANGELINI: I'm absolutely staggered by what I could see. The surgeon cut a large chunk of left ventricle and then stitched it all back together, making the heart work in a much better way—is pretty astonishing. I've never seen anything like this. I didn't think something like this was actually possible.

WILL LYMAN: There was no information on the surgery in any medical journals. Most of Angelini's colleagues had never heard of it. There was only one way to learn more. Dr. Angelini decided to visit Randas Batista on his ranch in southern Brazil. Dr. Batista trained in the United States and Canada, but he returned to his homeland where cardiac surgeons are few and he could have a greater impact on the lives of his patients.

DR. RANDAS BATISTA: Nice to see you.

DR. GIANNI ANGELINI: Nice to see you.

DR. RANDAS BATISTA: Welcome to the jungle.

WILL LYMAN: Over the last decade, he's built up this small local hospital almost single handedly. By American standards, the facilities are primitive.

DR. RANDAS BATISTA: This is our Intensive Care Unit. It's not a very sophisticated one in terms of equipment.

WILL LYMAN: Without much high tech equipment, Batista relies on basic clinical observation to assess his patient's progress.

DR. RANDAS BATISTA: So, basically, our main post-op care, this is what mainly I want, is to have pink feet, light urine and no blood in the bottle. Once you have a patient with this, I don't care about the monitoring. All I care—this is my monitoring.

WILL LYMAN: Batista's homey approach hasn't stopped him from staging a full attack on enlarged hearts.

DR. RANDAS BATISTA: This is a chest x-ray of this patient. As you can see, it's a very big heart. Usually, a normal heart, as you know, comes here. This whole thing will be excised and the heart will just look like a normal size heart.

WILL LYMAN: Dr. Batista believes that the size of the heart is directly related to how well it functions. Normally, oxygen rich blood flows into the left side of the heart from the lungs. The left ventricle is responsible for pumping it out to the rest of the body. When the heart becomes diseased from blocked coronary arteries or a virus, it sometimes dilates or swells. With the muscles stretched thin, the contractions become sluggish and weak, and the left ventricle is unable to pump out enough blood. Blood backs up in the heart and the lungs resulting in congestive heart failure. The rest of the body is robbed of needed oxygen and nutrients. In countries like Brazil, expensive medicines and heart transplants are severely limited. With no other options for his patients, Dr. Batista needed to come up with a new approach. He decided to decrease the heart size by removing a large section of the left ventricle. He reasoned that the muscle will then regain its ability to contract efficiently and pump the blood forward. Most surgeons don't believe it can work until they see it.

DR. GIANNI ANGELINI: I'm prepared to listen to anybody, but here is a guy who is telling us now to cut heart in a certain way, that I've been taught for twenty years that it's the last thing you should ever do because then the patient will die. So I was confronted by somebody who was turning all my knowledge, if you like, upside down.

WILL LYMAN: During the surgery, the function of the heart will be taken over by a bypass machine. Empty of blood, the heart continues to beat, even when Dr. Batista cuts out a large piece of muscle.

DR. GIANNI ANGELINI: This is frightening.

DR. RANDAS BATISTA: The coronary arteries start bleeding, so we have to stop their bleeding. The right ventricle is full of blood. Let it go. I can just improve the drainage. Hold this, too, both.

DR. GIANNI ANGELINI: I don't think I've ever seen anything like this, in Great Britain or anywhere else in the world.

DR. RANDAS BATISTA: This is the piece that came out. See, it's still beating.

DR. GIANNI ANGELINI: It's pretty astonishing. I don't know how something like this now is going to work in ten minutes or if it will work in ten minutes. This is possibly the most amazing thing I've ever seen in heart surgery. The concept that you can slash the heart at the left ventricle, literally wide open, as you could cut across an apple, is something that I think is beyond the imagination of any cardiac surgeon. Certainly beyond my imagination. Having seen the heart wide open, cut like that, I didn't think he could possibly put it together and make it work, and the heart worked immediately and immensely better. The heart is pumping all right.

DR. RANDAS BATISTA: The heart is pumping OK.

DR. GIANNI ANGELINI: This may be an emotional reaction just after I've seen this for the first time, but in my view, this is the best thing—it has happened in cardiac surgery in the last thirty years.

DR. RANDAS BATISTA: The surgery is over.

WILL LYMAN: How did this unknown surgeon in rural Brazil come up with such a revolutionary idea? Growing up on a farm and surrounded by animals, the young Batista was fascinated by anatomy, especially the anatomy of hearts.

DR. RANDAS BATISTA: Throughout my life, every time I would come to a dead animal, I would dissect their hearts. And this snake for instance, this snake killed a calf. And interestingly enough, by dissecting this snake heart and the calf heart, I could see they are quite similar. Both have the same ratio between the size of the heart and the amount of muscle.

WILL LYMAN: Finding that all the farm animals had a similar ratio between the size of the heart chamber and thickness of the muscle, Batista reasoned that this ratio must be crucial to heart function. The surgeon did some experiments on sheep to test his ideas. Encouraged by what he found, he began to try out his theory on human patients with enlarged hearts.

DR. RANDAS BATISTA: If their heart is not within this ratio, this patient must be in some kind of heart failure. Once you see that what is diseased is the size of the heart then the answer is easy, you decrease the size of the heart. All these bottles represent the patients we operated on. This piece came from Marco, the twenty-one-year-old boy that could be dead by now. This is his scar, a regular routine scar for a heart surgery. He, before his surgery, was really sick. He couldn't do anything. He couldn't swim, he couldn't play soccer, he couldn't—he could barely take a bath. And for a twenty-one-year-old boy, that's a miserable life. This is the piece of his heart we had to take out. As you can see, this is quite a good amount of muscle.

WILL LYMAN: Marco Bushman seems to have made a complete recovery. But Dr. Batista admits that up to forty percent of his patients died in the year following the surgery. Unfortunately, even this number is uncertain, because Batista's follow-up records are incomplete and many of his patients have disappeared. In spite of the lack of data, Dr. Angelini was so impressed by what he saw in Brazil, he returned to England determined to perform the surgery himself.

DR. GIANNI ANGELINI: I became absolutely obsessed with this operation. I wanted to do it, I wanted to bring something new to this country from which a lot of people would benefit.

WILL LYMAN: Before he can try out a new operation, Angelini must get permission from the Bristol Royal Infirmary's Ethics Committee. Because the procedure is unproven, the committee insists that the surgery be offered only in the most desperate cases—to patients who are near death and have no chance of a heart transplant. One such patient is seventy-year-old, John Coldrick. John is bedridden and completely dependent on his wife, Joan.

JOAN COLDRICK: We are living on borrowed time, really. I mean, every day's a bonus. This is how we look at it now. But it's hard. He gets terribly, terribly breathless. He just cannot breathe at all. I get very frightened, and then I think I tend to fuss over him which makes it a little bit worse. But, you just can't help it, can you? There you go.

WILL LYMAN: John and three other men will be among the first patients in England to undergo the new procedure. All are suffering from congestive heart failure and have severely enlarged hearts. Two of them are about seventy-years-old. The youngest is sixty-four.

DR. GIANNI ANGELINI: It is a bit of a paradox that we are trying to prove the potential of an operation but we are forced to start from the worst possible cases.

WILL LYMAN: Unlike the patients in Brazil, these men will be closely monitored with sophisticated tests. The size and performance of their hearts will be carefully measured before, during and after surgery. The ethics committee has insisted that Randas Batista fly in from South America. As the team prepares to make history, Dr. Angelini is well aware of the risk he's taking.

DR. GIANNI ANGELINI: It's the sort of thing for which you can get a lot of criticism if things were to go wrong. It's a gamble for the patient and it's a gamble for myself. I'm trying to introduce an operation which carries some considerable risk of mortality, at least compared with what we are used to nowadays. All right, go on bypass.

WILL LYMAN: As in Brazil, the function of John's heart is taken over by a bypass machine, even though it continues to beat.

DR. TOMAS SALERNO: Was the count correct in the last case?

DR. GIANNI ANGELINI: Yeah, cut this piece, beyond there. Yes, yes. Scissors.

DR. RANDAS BATISTA: Let me help, here. You can just let it go. That's good. Thank you.

WILL LYMAN: With Dr. Batista instructing, Dr. Angelini prepares to make the first incision into John's heart.

DR. GIANNI ANGELINI: All right, let me think a bit now. This is the left anterior descending and this is the part of the heart which is going to be resected in between the two papillary muscle.

DR. RANDAS BATISTA: The circumflex are good. The posterior is good.

DR. GIANNI ANGELINI: So I start from here?

DR. RANDAS BATISTA: Yes, you start from here, open this much. And then we'll take a look inside. Before we fix the mitral, we'll take the muscle out—will make it easier for you.

DR. GIANNI ANGELINI: All right. Scissors? This is it, yeah? No, no. I need some big scissors like Dr. Batista likes. Now I understand why he likes big scissors.

DR. RANDAS BATISTA: Can you turn the vent up a little bit?

WILL LYMAN: Dr. Angelini is doing something that he once believed would kill any patient.

DR. RANDAS BATISTA: Yeah, go, cut. Chop. Another one, another cut. Keep going, keep going. You always, big, big chunks. Cut. OK. That's good enough.

DR. GIANNI ANGELINI: This is it, yeah?

DR. RANDAS BATISTA: You can take more out. Now you can close it. That's all you have to do.

WILL LYMAN: The cutting is complete, but John's heart must now be stitched up and weaned off the bypass machine.

DR. TOMAS SALERNO: It has to be higher, cause it—where blood is flooding out, it's from the left atrium. A little bit more, that's good. Thank you.

DR. GIANNI ANGELINI: This heart looks really good, it's really bouncing away.

WILL LYMAN: John's echocardiogram shows immediate improvement.

DR. PETER WILDE: The heart has become smaller and contracts better. This is John's heart now, much smaller, much better contracting and this really is a dramatic difference between what we saw before and what we're looking at now. I'm absolutely amazed. I would never have expected it to improve this much.

WILL LYMAN: Over the next two days, all four patients undergo the procedure. In each case, the heart's function improves dramatically in the operating room. The surgical team is jubilant. But within twenty-four hours, the mood changes. One patient's heart suddenly starts bleeding and the man quickly dies. A week later, a second patient dies, this time from kidney failure. John Coldrick recovered from the surgery and returned home, but three months later, he too, died.

DR. GIANNI ANGELINI: With the knowledge that I've got now, I don't think I would touch again a patient like John Coldrick because it was a patient at the end of the road, and I don't think these are the right group of patients to operate on because the mortality's going to be probably too high. We have to intervene much earlier.

WILL LYMAN: More than a year after the surgery, the fourth and youngest patient is doing well. And Dr. Angelini remains convinced that with the right patients, the operation can save lives. The deaths in England did nothing to diminish Batista's faith in his new procedure, but they did raise concerns for many U.S. doctors. Dr. Lawrence Cohn is Chief of Cardiac Surgery at Boston's Brigham and Women's Hospital.

DR. LAWRENCE COHN: There is a risk to these operations. It may not help some people. Some people may die after these operations. So like any operation, we want to make sure that we know the best indications for it, who's going to benefit, and what are the long term results of this. But in the meantime, we should establish protocols to aggressively go after the information.

WILL LYMAN: At Cohn's invitation, Batista came to Brigham and Women's to present his radical theory to some of America's top heart specialists.

DR. LAWRENCE COHN: Now the subject today is actually quite a controversial one.

WILL LYMAN: Some of the Boston doctors also went down to South America to review the over two hundred cases Batista had performed. One of them was cardiologist Lynne Warner Stevenson, who was disappointed by what she found—or could not find—in Batista's files.

DR. LYNNE WARNER STEVENSON: We don't know how many of those patients are alive. We don't know how they're feeling. We know that a few patients are alive, because they've come back to thank him. But we don't know what happened to the rest. Batista has described himself as an artist rather than a scientist. And clearly, we need art in medicine as everywhere else, however some science has to come into it before we can offer this as a product to people who are desperate.

WILL LYMAN: Batista got a similar reaction when he visited another venerable Boston hospital, Massachusetts General.

DR. WILLIAM DEC: We need to know a lot more about this operation. We need to know what types of patients should we select. We need to know how good does the heart really look at six months, at a year, at five years. We need to know carefully how many patients survive at various points in time after the operation. If they don't survive, why are they dying? Are they dying of congestive heart failure again? Are they dying of complications of the surgery, or are they dying of heart rhythm problems? So that all of those things, we really need much more information about before we can really assess the role of this in the treatment of heart failure.

WILL LYMAN: By the Spring of 1996, dozens of American surgeons were flocking to Brazil to see Batista in action. Among them were doctors from the Cleveland Clinic, one of the world's leading centers for heart disease. Cardiologist Randall Starling quickly overcame his initial skepticism.

DR. RANDALL STARLING: What was really amazing to see in the operating room was a patient that came in with a very enlarged heart that was very, very weak with low blood pressure, go through the operation and then without any difficulty whatsoever, come off of the heart lung machine, sustain a good blood pressure and look like they're doing very, very well.

WILL LYMAN: His colleague, Surgeon Patrick McCarthy, was equally amazed and eager to try the new procedure at home.

DR. PATRICK McCARTHY: When I came back from Brazil, I had lots of patients here waiting for a heart transplant that I thought would benefit from this operation. I was convinced enough by what I had seen that even though I knew that it was going to be very controversial, I almost thought it was unethical not to do it.

WILL LYMAN: Based on McCarthy and Starling's strong recommendations, the Cleveland Clinic decided to forego the more formal approval process usually applied to experimental surgery. Less than two weeks after his return from Brazil, McCarthy was performing the procedure himself in front of TV news cameras.

BILL SANOWSKI: When they cut that piece of heart out, it was still alive. It was still beating.

WILL LYMAN: Bill Sanowski and his wife, Marie, saw the coverage at their ranch in Oregon.

BILL SANOWSKI: We thought that would be ideal for me. The rest of me is in real good physical shape, nothing else wrong with me. No other problems, other than my heart.

WILL LYMAN: At 71, Bill Sanowski's once strong body has been ravaged by heart diseased.

BILL SANOWSKI: I used to be able to take a four hundred pound calf and just pick him up and flip him on the ground, fold his leg back and I'd have him. But my strength little by little gave out. I couldn't get the jobs done. I could feel everyday I was slipping a little bit.

WILL LYMAN: Desperate for a cure, Bill was soon planning a trip to Cleveland. By this point, Patrick McCarthy had performed the Batista procedure thirty-seven times, more than any other U.S. surgeon.

DR. PATRICK McCARTHY: Is this the missus?

BILL SANOWSKI: This is the missus.

DR. PATRICK McCARTHY: Hi, how are you? Nice to meet you. Well, I've been hearing a lot about you from the cardiologist. I'm going to just sit down here and talk to you for a bit and hear the story from you.

WILL LYMAN: Bill is one of two thousand patients who contacted the Cleveland Clinic about the new operation. So far, fewer than two percent have met the hospital's strict selection criteria.

BILL SANOWSKI: You've been hospitalized for heart failure, from what I understand, is that right?

BILL SANOWSKI: A few times yeah.

DR. PATRICK McCARTHY: How often have you been in the hospital?

BILL SANOWSKI: Oh, one, two, about five times.

WILL LYMAN: Many factors can rule a patient out, including coronary artery disease or a heart scarred from previous heart attacks.

DR. PATRICK McCARTHY: It sounds like otherwise you're a pretty healthy guy. All right, let me talk to you about it, though.

WILL LYMAN: After a barrage of tests, Bill finds out that he does qualify. Now the question is, does he understand what he's getting into.

DR. PATRICK McCARTHY: It's not a miracle, it's not a cure, OK? We can improve the heart function in most patients, but we don't make you completely normal. We don't make the heart function completely normal, OK? Right now what we're estimating is that for patients, about seventy to eighty percent are improved after surgery, not that you're running marathons or in the Olympics, but just feeling better and hopefully breathing easier and having more energy. OK? Some people feel much better, and if they do, that's terrific. That's good. But, we just want you to feel better. There is certainly a risk to your life to go ahead with this, OK? What we're telling patients and what we saw in Brazil is a fifteen percent risk to your life to go ahead with this kind of a surgery, OK? Having said that, we've done thirty-seven now and we haven't lost anyone, but still it is a risky operation and it's not something to take lightly, OK?

WILL LYMAN: The Cleveland Clinic's low mortality rate is due at least in part to their patient selection. While the British trial was limited to patients too sick or too old for a transplant, McCarthy deliberately started with people who were on the transplant list.

DR. PATRICK McCARTHY: Any other questions?

BILL SANOWSKI: I think that's it. Tomorrow morning at 11 o'clock we have a date.

DR. PATRICK McCARTHY: See you then. All right. You can start with nontransplant candidates, which is what other places have done, but you don't have that safety net. And so especially early, when you're learning how to do a procedure, you're on a tight rope without the safety net, and I didn't think that was acceptable.

WILL LYMAN: McCarthy has needed the safety net. After having their hearts reduced, several patients required additional surgery. For five of them, McCarthy installed an artificial pump in the chest that can assist the heart until a new organ becomes available. Out of the first thirty-seven cases, one has gone on to receive a heart transplant. Because he accepts people from the transplant list, McCarthy is operating on younger patients. A typical case is Linda Adams.

DR. PATRICK McCARTHY: Hi, Mrs. Adams. How are you doing? You're kind of sleepy?

WILL LYMAN: Up until six years ago, Linda was a hairdresser in Oklahoma. Then suddenly at the age of 43, she became ill.

LINDA ADAMS: From then on, I was never well. Tired all the time, and short of breath, so I haven't been able to do very much of anything.

WILL LYMAN: The diagnosis was idiopathic dilated cardiomyopathy—in layman's terms, an enlarged heart. Linda's doctors prescribed various medications, but her condition only got worse. Although she qualified for a heart transplant, Linda always hoped that another treatment would come along.

LINDA ADAMS: I was really happy that maybe there was something besides a transplant that could work for me.

DONALD ADAMS: How are you feeling? Still sick to your stomach? A little bit? OK. In fact, she was on the transplant list for a while and took her name off herself. She decided if she could hang on to the stage that she was in, she wasn't going to have a transplant, because after a transplant, there are no more options. Getting scared? A little bit? I'll be there, you know.

WILL LYMAN: Mrs. Adams, we think, is a very good example of a patient that we think is going to benefit from this operation. She's 49-years-old. She's very sick. She's in the intensive care unit and patients like that clearly don't have a lot of time.

LINDA ADAMS: I'm anxious to be well and be able to do some things, to go shopping and to play with my granddaughter outside, be able to do things with her, maybe go to the zoo. Things that I haven't been able to do in these six years. Bye-bye.

SHELBY HILL: Bye-bye.

BRAD HILL: See you in a little bit.

DONALD ADAMS: She said she'd take care of you when you got home. I know it's still experimental, and you know, that's always something to deal with, but someone's got to be on the cutting edge of this thing and these guys here have taken the chance, and it's helped a lot of people. She's excited about the chance to get better.

WILL LYMAN: Linda's chance may be affected by the changes Dr. McCarthy has made to the surgery. In Brazil and England, the heart continued to beat during the procedure.

DR. PATRICK McCARTHY: We used to do the operation with the heart beating at this point, but I stopped doing that because it's easier to see to do it this way.

WILL LYMAN: Dr. McCarthy stops the contractions with special drugs, a technique used during most American heart surgery. With the heart still, the surgeon can make more precise cuts and carefully avoid important blood vessels.

DR. PATRICK McCARTHY: Now what I'm going to do is open the apex of the heart right here. Jim, can you hold on either side, please? OK. The good thing that I already notice is that this heart muscle, itself, is not bad. No scar, indicates to me that we're going to do well here today. Wait, can I have this one. There you go, Jim, right there, a little bit more. All right, right there. Blue dye, please. For research purposes, we mark what used to be the apex of the heart. We do a lot of studies of the molecular properties of this heart muscle. It will help us understand why the operation works. And they need the blue dye there so that they can get oriented to the piece of heart muscle that I'm removing.

WILL LYMAN: The central goal of the surgery remains unchanged. Several pieces of Linda's left ventricle are removed.

DR. PATRICK McCARTHY: This is the piece of heart that we've removed so far. Now what I'll do is I'm going to be able to remove more heart muscle. By removing additional heart muscle, I'm really going to be able to reduce the size of this heart.

WILL LYMAN: Concerned about previous bleeding episodes, Dr. McCarthy employs a different method for closing the heart.

DR. PATRICK McCARTHY: We're using these strips of soft felt to close the heart muscle, because I want to do everything that I can, let go please, to minimize the possibility of bleeding, and I think that these strips of felt will help with that. Can you switch to retrograde, please? I'm going to over-sew this in two layers, just to be certain that they're—depending on the thickness of the muscle, it makes a pretty good sized gap. You could also bevel the edges.

WILL LYMAN: After the muscle is sewn up, Dr. McCarthy has to get the heart beating again. At first, the contractions are irregular.

DR. PATRICK McCARTHY: Now I'm going to give the heart a little electric shock and put it back into a regular rhythm. Hit it. Charge to 30. Hit it. Better. OK.

WILL LYMAN: The entire surgery lasts an average of three to four hours. As the heart comes off the bypass machine, it seems to be responding well. But as the team prepares to move her out of the OR, something goes wrong. Linda's heart starts to fail and the surgeons must insert a small, thin balloon into her aorta. The balloon expands and deflates, helping push the blood forward and keeping Linda alive.

DR. PATRICK McCARTHY: I'm worried about her. She's the first of the thirty-seven patients with this procedure that we've had to use it on. And so, that's sort of a bad sign. I don't like to have to do that.

WILL LYMAN: As Linda lies in critical condition in the Intensive Care Unit, Bill Sanowski is heading to the operating room.

BILL SANOWSKI: I'm feeling real good. I'm ready to go. I've been ready to go for about six months now. You don't really want me. Bye, honey.

MARIE SANOWSKI: So long.

BILL SANOWSKI: For a little while. Like I told the doctors, if they do a good job on me, I'm ready for another thirty years.

DR. PATRICK McCARTHY: Mr. Sanowski is very typical of many of the patients that we do. His heart function's very, very bad. He's very sick. When you look at this heart, it's barely moving.

DR. GREG SCALIA: It's hard to imagine how this person could actually have any activity with this severe level of functioning.

DR. PATRICK McCARTHY: Yeah, we just saw him right before surgery, and he actually, when you look at him, doesn't look too bad. He's very symptomatic, obviously, but his heart's hardly moving at all. Wow. This is big. Huge, huge heart. This is one of the largest looking hearts that we've done.

WILL LYMAN: When the heart becomes this big, the valves inside also stretch out. Leaky valves make the heart an even less efficient pump. The large yellow plume on Bill's echocardiogram reveals that blood is leaking backwards through the mitral valve with every beat. Bill's diseased and weakened heart is only pushing forward a small fraction of his blood. Dr. McCarthy believes that one of the most important elements of the surgery, in addition to the removal of muscle, is the intricate repair of the valves. This often involves attaching a small ring around the valve opening. The ring provides support and prevents the valve from leaking.

DR. PATRICK McCARTHY: Cut right there, please. Squirt it. Cut this. Hold that, Michael. Knife please. And I will take the bulb syringe today. OK, so now the valve's completely competent, there's no leak at all. Ta-da. How's that?

WILL LYMAN: After Dr. McCarthy fixes the valves and removes a large section of Bill's heart, the organ pumps much more efficiently.

DR. PATRICK McCARTHY: Take some volume off, please. We have removed a lot of heart muscle today.

WILL LYMAN: Bill will be watched closely in the Intensive Care Unit for several days.

DR. PATRICK McCARTHY: In general, things look very encouraging. You're only twenty-four hours out.

WILL LYMAN: In a nearby bed, Linda Adams has weathered her crisis.

DR. PATRICK McCARTHY: I think probably maybe tomorrow afternoon we might move you out of the ICU.

WILL LYMAN: She is off the balloon pump and back on track. Had Linda undergone the surgery in Brazil, with its less sophisticated ICU, she probably would not have survived. In his efforts to help his patients, Dr. Batista is severely limited in his resources. But he's unhampered by government or institutional regulations.

DR. LAWRENCE COHN: He is in a totally unregulated environment, and he can do whatever he wants, whenever he wants it. And that's a bit different than the environment that we're living in.

DR. RANDAS BATISTA: Here, I would be in jail, because the things I do there, I don't care much about the laws. I think I'll do what I think is the best for my patients. That's what I did. I have a commitment with my patients. I don't have a commitment with my—the laws where I live. So for that aspect, here, I would be in jail, because I wouldn't—I wouldn't follow their rules.

WILL LYMAN: In America, the rules vary from hospital to hospital. But the ultimate hurdle is scientific peer review. For Batista's surgery, that process is just getting started. The Brazilian doctor recently presented a paper at the Society of Thoracic Surgeon's annual meeting.

DR. PATRICK McCARTHY: This meeting is one of the two major heart surgery meetings of the year. And so this is the first time that his paper was accepted for presentation. Before this, many people had heard about it, but it had been very much sort of word of mouth or through occasional seminars, but not at a major cardiac surgery meeting like this.

WILL LYMAN: Tomas Salerno of Buffalo General Hospital co-authored Batista's paper, and organized a special seminar attended by over eight hundred surgeons.

DR. TOMAS SALERNO: The people who are here, some of them are skeptical, some of them are coming here to watch and see. But as you can see, this meeting is composed of very important institutions, which brings a lot of prestige to what Batista has done.

WILL LYMAN: Among the big names was Denton Cooley, one of the pioneers of heart surgery. Cooley's hospital, the Texas Heart Institute, along with the Cleveland Clinic and Buffalo General, are just three of the centers now investigating the Batista procedure in the U.S. With so many patients dying from heart failure, everyone is looking for a low cost alternative to heart transplant. But many heart specialists aren't ready to embrace Batista's solution because there is still no long term follow-up. And there are fears that dozens of small hospitals are trying the surgery before the true and lasting effects are known.

DR. LYNNE WARNER STEVENSON: Surgeons are doing it everywhere. Often these are surgeons who do not have the usual experience with assist devices, with transplant, with ways that we would bail out a patient who didn't do well. So there is a lot of concern that this procedure is being too widely tried. If this were a new drug, we wouldn't have every doctor trying it on three patients. It would go through careful trials where everything is recorded, where everything is very carefully watched, before it would be available to the majority of physicians or to the majority of patients.

WILL LYMAN: In response to these concerns, the Society of Thoracic Surgeons recently published guidelines, recommending that the procedure only be performed under a strict scientific protocol in centers experienced in heart transplant.

DR. PATRICK McCARTHY: The jury is still out, and I'm still cautious about it. So I don't know yet for sure whether it's going to be safe and effective. It's still early. But I also know that it looks encouraging. There are people that are very conservative in cardiology and in cardiac surgery, and they're just waiting to see how our experience does with more time. And that's appropriate. That's fine for people to sit back and wait. But you have to understand the only way to find out is to do it.

WILL LYMAN: Until more research is done, every patient who goes under the knife is taking an uncertain risk. For some, the risk may pay off. Just six weeks after her surgery, Linda Adams has experienced a dramatic improvement.

LINDA ADAMS: It's—it's a miracle. I can do things today that a year ago I would have told the person that they were lying. I had given up on my life, and I thought that my life would be either sitting in the recliner or being in the hospital, and now I feel so good. I'm able to walk, I'm able to cook, and I take care of laundry and I play with my granddaughter. Are you helping, Shelby?

SHELBY HALL: Do I need to be helping?

LINDA ADAMS: You're just helping by watching? Things that I thought was coming to an end, I'm able to do and enjoy it.

SHELBY HALL: Gold!

LINDA ADAMS: Gold? I don't see any gold.

SHELBY HALL: We're going to dig it.

LINDA ADAMS: I enjoy every minute.

SHELBY HALL: This is fun!

LINDA ADAMS: It's went beyond my expectations. Are you cold?

SHELBY HALL: No.

LINDA ADAMS: You're fine?

SHELBY HALL: It feels good out here.

LINDA ADAMS: It sure does.

WILL LYMAN: So far, Linda is one of the lucky ones. Out of Patrick McCarthy's first fifty patients, three have died, and twelve others have not improved. Back in Oregon, Bill Sanowski's recovery has been slow.

BILL SANOWSKI: Well, I guess my circulation is a lot better, but as far as the breathing is concerned, that hasn't improved that much. Maybe it has and I don't realize it, but it just feels like I have to watch myself breathing. Cause it's still a little hard. Breath doesn't come that easy.

WILL LYMAN: In the four months since the surgery, Bill has been hospitalized three times. But in spite of his setbacks, he remains hopeful.

BILL SANOWSKI: It's giving me a chance to get better. I didn't have any chance before. None. I think I'll make a full recovery. I don't think anything's gonna happen to me. And if I don't, I don't. I don't worry about it that way, either. I tried the best I could. And you give it your best, that's all you can ask.

WILL LYMAN: The future of these patients and others is uncertain. Whether their hearts improve, or whether their disease returns, how long they live and how good they feel will ultimately be the true test of this new treatment.

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Coming up on NOVA, Dao and Duan are like any other little girls, except for one thing, they are conjoined twins. Can doctors find a way to safely separate them? Siamese Twins. That's coming up on NOVA.