MEDICINE

A surgical artist

Interview with Dr. Randas J. Vilela Batista.

In 1983, in Curitiba near Rio de Janeiro in Brazil, in a tiny rural hospital with the most rudimentary of facilities, 36-year-old Dr. Randas J. Vilela Batista performed an unconventional, path-breaking procedure called ventricular remodelling, trimming an enlarged heart to normal size.

The established medical schools received the news with disbelief, scepticism, even ridicule, for the procedure defied a cardinal principle in cardiology - that live tissue of the heart not be removed. But today, after 16 years during which a number of demonstrations of the procedure were performed in hospitals and international seminars on it were organised, the "Batista Procedure" has found a certain level of acceptance worldwide. Experts in the United States, Japan and Europe see it as a "new course in cardiac surgery" and "a breakthrough in treating certain types of heart failures". Hospitals in Buffalo, Cleveland, Texas, Louisville and Boston in the U.S. as well as in Germany and Japan have adopted the procedure with good results. Research is being carried out on this procedure in different parts of the world.

M.MOORTHY

Dr. Batista, who has performed 1,000 of the 3,000 procedures of this type done until now, says that it has gained greater acceptance abroad than in his own country. However, Dr. Batista, who calls himself a "surgical artist", is not overly concerned about numbers. To him what matters is that "dying patients are given a chance to survive". While the Batista Procedure could well be a substitute for the heart transplant procedure in the case of some persons, it certainly serves as an intermediate procedure for those waiting for a donor heart.

After acquiring a medical degree in Brazil, Dr. Batista (his first name, Randas, is pronounced Handas; born in 1947, he was named after Mohandas Karamchand Gandhi) went to Boston in 1972 to specialise in general surgery. After spending six years there, he went to Canada, England and France to learn new cardiac surgical techniques and returned to his native town, Curitiba, south of Rio, in 1983. Since then he has lived in the small town, content to work for and with the poor. Recently, he set up a Foundation for cardiac patients at Curitiba.

Dr. Batista was recently in Chennai to demonstrate his procedure at the Institute of Cardio-Vascular Diseases, Madras Medical Mission. He spoke to Asha Krishnakumar about his technique, the underlying scientific principles, the advantages of the procedure, the resistance it faced initially and its acceptance now. Excerpts from the interview:

When did you employ your unique surgical procedure first?

The year I started my practice in the small hospital in Curitiba, I got an opportunity to try this procedure. I performed the procedure on a poor 24-year-old woman from Paraguay: she had an Ebstein Anomaly - a congenital condition in which the right ventricle becomes thin and big and malfunctions. The only way she could have survived was by this procedure. No one wanted to operate on her. But we were not willing to give up so easily.

First, we corrected the tricuspid valve and ASD. She did not come off the extra-corporeal circulation pump, commonly called the bypass, after the operation. To help her, we had to reduce the size of her right ventricle and the only way to do that was by this procedure. So we went ahead and did it. That was the first time.

Had you done some theoretical work on this procedure or did it just happen on the surgical table?

My interest in cardiology goes back to my childhood. Later, I was surprised to learn that although the heart size varied - as between a snake and a buffalo - there was an equilibrium of the forces inside. The shapes were the same. I realised that what was crucial was the equilibrium of forces; pressure was not important, tension was. If the heart was big, the ratio between the muscle mass and the radius would not be normal. The equilibrium of forces would, thus, not be normal and the increased tension would prevent the heart from contracting efficiently. So, if I cannot provide the heart with more muscle to contract efficiently, I need to reduce its size.

I thought about it for quite some time. And all of a sudden the principle struck me. And I went ahead with the procedure. I also worked out a formula:

The heart muscle mass = 4 x (heart radius)^3.

This is the criterion I use while reducing the size of a heart.

Could you provide some more details of the Batista Procedure?

It is a ventricular remodelling procedure used on end-stage heart patients to excise an enlarged heart. The heart can get enlarged owing to several reasons - congenital malfunctions, valvular diseases, infections and so on. Tension is most important for the efficient contraction of the heart. So, when the heart is enlarged, the pressure in the heart is the same, but the tension is very high. This impedes heart contraction. Hence, there is a need to bring the heart to normal size, and the only unconventional method is to excise it.

This is done by cutting out a large slice of living muscle from the main pumping chamber, which is then stitched together when the heart is still beating. It can be done at any age. I have done this procedure on a six-month-old baby as well as on a 95-year-old woman.

What are the chances of recurrence of the enlargement?

There is a 10 per cent chance. It depends on how much of the heart is excised. If the size has been brought to normal, then the chances of recurrence are low.

How was the procedure received initially?

First, everyone thought I was crazy as it went against the conventional wisdom of not removing live tissue. In Brazil they wanted to get my diploma and my licence cancelled. In 1993, Dr. Tom Salerno from the Buffalo General Hospital came to Brazil and saw me do this procedure. Initially he too thought I was crazy. Then, in 1995, he invited me to Boston for an international meeting. At the conference they did not allow me to talk about this procedure and I was asked to present a paper on "Lung Volume Reduction". I started by saying that lung volume reduction is a good procedure, but it was not new, and that Jewish people had been doing this for 2,000 years. Then I went on to talk about the Batista Procedure. They all thought I was mad.

In a way, their response was good because it had one effect: they started to take notice of me and think about the procedure. Some thought I was crazy, but others thought there was something in what I said. Thereafter, some doctors from the U.S., Japan and Europe came to Brazil to see me do the operation, and were convinced about the efficacy.

Dr. Salerno started helping me. He started talking about it in international conferences, apart from doing the procedure himself.

Is the Batista Procedure an alternative to a transplant?

For some it could well be. Many of my patients are leading a normal life after a Batista. My first patient from Paraguay is still alive, 16 years after the operation.

Some sections within the medical community say that Batista is not a scientific procedure, that the success rate is not very good, and so on...

Most of my patients are poor. They do not come for a follow-up. There is no way I can keep track of them. I do not even have the staff required to do a follow-up. Many patients disappear into the Brazilian jungles after the operation. I do not even know whether they are alive.

A good proportion of my patients consist of those who have been given up by other doctors. I am not overly concerned about results. My principle is that I should give everyone a chance to live, however hopeless the case. I do not select my patients.

I do not have the facilities to keep tabs on my patients. I did not even have the facilities to address the three major, common post-operative problems - bleeding, renal failure and arrythmia.

Also, only through experience can one do this procedure well. How much to excise, where to excise, how to excise... these are aspects that one perfects over time.

We cannot give figures right now. But I am sure that will not be the case with the next 1,000 such procedures I do. Even though I do not have any reliable figures to show right now, considerable scientific data are available on this procedure done in various other hospitals in different parts of the world.

According to data available with the Cleveland Clinic, patients who have undergone the Batista have the same survival rate as patients who have undergone transplant - 90 per cent after one year. But in the case of the Batista, post-operative care and costs are nil. You need no immunosuppressants, no frequent tests and there is no worry of infection and rejection. If you have survived the operation for three years, you have a good chance of leading a normal life after that.

In a country like India, where there is donor scarcity and where hardly 1 per cent of those waiting for a donor heart get one, this procedure is a breakthrough. Several patients who would otherwise die waiting for a donor heart can be saved and they can live absolutely normally for the rest of their lives.

What further research is being done in this area?

A lot of controlled experiments and research are being done in Berlin by Dr. F. Konertz, in Munster (Germany) by Dr. P. Lunken Heimer, in Japan by Dr. F. Kawaguchi and in Louisville by Dr. Bob Dowling.

A diagram setting out the principle of the Batista Procedure, technically called Reduction Ventriculoplasty, in which a dilated heart (the dilation shown as a dotted line) is restored to near-normal size after excising a slice of living muscle from between the anterior and posterior papillary muscles from the left ventricle, the main pumping chamber. After the excision, the left ventricle is sutured while the heart is still beating.

Earlier, during a heart failure, the ventricles were thought to be dead. Their size itself became the disease. No one thought they could be repaired. Now there is a lot of research being carried out on ventricles.

To begin with we used to look at the ventricles as being good or bad. But now we find that they grow differently in different directions. So different procedures can be used to excise the enlarged portions. All that is being worked out now.

After the Germans became convinced about the procedure, they worked on it and found that it conforms to the Laplace mathematical law. That is, Wall tension is equal to

(Pressure x Heart Diameter x Pi) / 2 (thickness of the heart).

The procedure has a very sound mathematical basis and is slowly being accepted. But still there is a lot of opposition to this. Some doctors and pharmaceutical companies are against this. They are scared that they will not be able to make money from this procedure.