Broken Hearts: The Tangled History of Cardiac Care

12. The Case of the Missing Complications

After spending fifteen years refining the techniques of cardiac surgery on patients with congenital or rheumatic heart disease, cardiac surgeons in the 1970s took on a new problem: coronary artery disease. Coronary artery surgery had existed on the fringe of cardiac surgery since the 1930s, but it was overshadowed by valve surgery in the 1950s and 1960s. A few surgeons, however, had recognized the potential of a bypass procedure. With coronary artery disease killing one-quarter of all Americans, the market for this promising operation would be vast. When Cleveland Clinic surgeons published their first bypass surgery case series in 1968, surgeons from all over the nation flocked to do the procedure. By 1977, more than one hundred thousand bypass surgeries were being performed each year.1 The growth, however, occurred amid a striking absence. Even though physicians had assiduously studied the cerebral complications of valve surgery, they at first paid little attention to these same complications with coronary artery bypass grafting. How and why this happened illuminates the forces in medicine that make complications so difficult to study. chapter twelve The Case of the Missing Complications 150 Complications Early descriptions of bypass surgery focused on its positive features. Surgeons at the Cleveland Clinic, for instance, emphasized how well the operation restored blood flow to the heart, how well it relieved angina, and how many patients survived the procedure. Of their first ten published articles about bypass surgery, only one mentioned neurological outcomes at all: two patients had suffered strokes in a series of eighty patients who’d had bypass surgery combined with another surgical procedure. Although surgeons paid close attention to other sorts of complications of bypass surgery, including heart attacks, arrhythmias, bleeding, heart failure, and clotting problems, they did not seem to consider cerebral outcomes (or, at least, they did not document them). Surgeons in Milwaukee and New York also published early and influential bypass surgery case series, and only one of the first five reports from each city mentioned cerebral complications. As surgeons gained more experience with the procedure, they published ever larger series to demonstrate their superior outcomes. Denton Cooley’s team at the Texas Heart Institute described 4,522 consecutive cases, and they noted that some of their patients eventually died of strokes (or cancer, ulcers, murder, and suicide), but they made no mention of any postoperative neurological or psychiatric problems.2 The inattention to cerebral complications can be quantified. Of the first two hundred articles published about bypass surgery between 1968 and 1973, nearly all described the direct cardiac effects of the procedure: graft patency (97% of the articles), relief of angina (84%), and impact on cardiac function. Discussions of complications, when present, focused on operative mortality (86%), arrhythmias, and myocardial infarction. Neurological damage was noted in some (19%), usually as part of a listing of causes of death. Only four made more than a passing mention of neurological or psychiatric outcomes. Textbooks of the era either did not address complications at all or discussed only operative mortality, heart attacks, and graft failure.3 In 1971 the American College of Chest Physicians surveyed surgeons about their experience with bypass surgery. It requested data about angiography, graft patency, angina, and in-hospital fatalities, but not about complications in general or cerebral complications in particular.4 WhenacollaborativegroupofVeteransAdministrationhospitalsconducted the first major randomized trial of bypass surgery, they initially reported operative mortality, angiographic outcomes, ventricular function data, and longterm survival rates. Subsequent reports described quality of life, including outcomes such as nonfatal heart attacks, angina, exercise capacity, and work The Case of the Missing Complications 151 status, but not neurological or psychiatric status. Researchers cast their net wide, with publications on the characteristics of noncompliant patients and on the cerebral complications of angiography (4 strokes in 3,044 angiograms). Only one of the forty-six publications that emerged from this trial mentioned a cerebral outcome related to bypass surgery, a single patient who did not regain consciousness after the operation.5 The Coronary Artery Surgery Study (CASS), orchestrated by the National Institutes of Health, followed a similar trajectory. Although the researchers collected data about patients’ neurological histories and any observed neurological or psychiatric complications, the study’s primary reports focused on operative mortality, long-term survival, and quality of life. Some of the scores of reports published in the 1980s did mention neurological outcomes, but only for particular subgroups, such as elderly patients, women, or African...