Heart smart

Dr. Li Poa pioneers ‘beating heart’ surgery at Enloe Medical Center

OFF-PUMP POA <br>Dr. Li Poa is the only surgeon in the Northstate, besides one in Redding, who operates on the heart while it is still beating, as opposed to the traditional bypass procedure. “Northern California has been lacking in off-pump,” he says. At Poa’s left in the operating room is Dr. Roger Stringer, a cardiac surgeon who is assisting in an operation on Bernard Campbell of Chico.

Dr. Li Poa is the only surgeon in the Northstate, besides one in Redding, who operates on the heart while it is still beating, as opposed to the traditional bypass procedure. “Northern California has been lacking in off-pump,” he says. At Poa’s left in the operating room is Dr. Roger Stringer, a cardiac surgeon who is assisting in an operation on Bernard Campbell of Chico.

Photo by Tom Angel

Team player: During our interview and the surgery, Poa insisted he should not be the focus of an article, passing on praise to the cardiac team as a unit. Present but not mentioned in this story were: Director of Surgical Services Bonnie Keegan, Registered Nurses Chuck LeFevers and Hannacho, Surgical Technician William Majors, Scrub Techs Jack Hoenig and Bill Cody, and Anesthesiologist Dr. Curtis Eldenburg.

Helen Campbell remembers reading about Dr. Li Poa when he first came to town last fall. She thought the doctor and his ultra-modern surgery techniques sounded interesting, but “it never even dawned on me that we’d have anything to do with this.”

Then, a couple of weeks ago, her husband, Bernard, was mowing the lawn when he felt a pain in his chest, and then another one. It reminded him of the pain he felt seven years ago, before he got a stent placed in a blood vessel near the heart to help keep it open. “I thought, ‘What the hell?'” says Campbell, as he sits in an Enloe Medical Center room waiting to be wheeled into the operating room, where Dr. Poa will apply his surgical skills to the 80-year-old’s heart.

In overall good health, Campbell is a candidate for heart surgery. But he won’t be undergoing the type of bypass operation that doctors have been doing routinely for the past 40 years, and how 90 percent of such heart surgeries are done. Campbell’s cardiologist has entrusted him to Poa, who is among the fewer than 200 cardiac surgeons worldwide who operates “off pump,” with the heart beating.

Poa is 37 and already an expert in the field, tapped to travel on cardiac teaching tours and have his lessons broadcast over the Internet. This year, he traveled to Asia with other prominent surgeons.

He was 15 when he started college, in Canada, where he had emigrated from Taiwan. Poa studied at Northwestern University Medical School and continued his training at hospitals in Pennsylvania and Southern California, most recently holding a position at Daniel Freeman Medical Center, where he was chairman of the department of surgery.

As an aside, he’s a trained lifeguard and in 1983-84 was a member of the U.S. Olympic cycling team. He also played tennis professionally.

Poa came to Chico in September 2001, largely because he and his wife, who is also a doctor, “really wanted to be in a small-town atmosphere” for the benefit of their children, ages 10, 8 and 6. They also have a baby on the way.

“As far as facilities and everything else, [Enloe] is like a luxury hospital,” says Poa, who set up a practice with Dr. Ronald Becker, a cardiac surgeon and the founder of Enloe’s Heart Program, who had sought him out to practice at Enloe.

Philip Wolfe, Enloe’s chief executive officer, says, “We were extremely excited that he and his family decided to come to Chico. … He brought something to our program that we didn’t have.”

Poa’s white coat reads, “cardiothoracic surgery,” and he wears a little pewter pin: a heart with a Band-Aid over it. He’s transplanted both hearts and lungs, and now other surgeons who operate at Enloe are learning off-pump surgery from him.

“Heart surgery has been done for about 100 years,” Poa explains. Even the heart-lung machine that is used during traditional bypass operations has been around since the 1950s. But while bypass procedures themselves are common and safe—skilled surgeons can easily repair veins in a bloodless environment—there is a down side to having one’s heart stopped for a period of time.

“It took us a while to figure out the drawbacks,” Poa says. Strokes can occur, either as a side effect of inflammation, or when the hole for the tube directed into the atrium leaves room for debris to enter. Fairly often, the patient has neurological changes such as short-term memory loss, a decrease in logic or creativity, or personality changes. Kidney failure, too, can result.

“Someone who wouldn’t be a candidate for normal surgery would be a candidate for off-pump,” says Poa, largely because the operation is less stressful on the body. The mortality rate nationwide for beating-heart surgery is 2.7 percent, compared to 4.9 percent for traditional cardiac-bypass surgery.

“God didn’t make us with our hearts stopped and our lungs stopped,” Poa says. “It’s pretty clear-cut: If you can perform a surgery off pump, it’s better on the patient.”

But it’s not as easy.

“The heart’s beating, and you’re trying to do it with the blood spurting all over the place,” says Poa, who uses clamps and cautery to stop bleeding. The trick, a handful of cardiac surgeons—"pioneers” in Brazil, Italy, Argentina and Peru—discovered about 25 years ago, is to take the heart as it is but adapt their techniques to compensate for the movement and blood flow.

POA’S PHILOSOPHY <br>In a Third World or socialist country, Poa says, patients who aren’t good candidates for traditional bypass wouldn’t get surgery. But here, “It is not at our behest to determine how to limit our resources.” If someone decides to have the surgery, “We will give him or her that chance.”

Photo by Tom Angel

“We learned to do it with the heart coming up at us,” Poa remembers.

Some in the medical establishment were resistant. They had already spent years developing and practicing bypass surgery, and Poa says they wondered, “Why would you want to do it with a beating heart again?”

For Poa, the reasoning is simple. “These are all patients’ lives. … I don’t need the challenge for myself.” His team takes on high-risk patients because they are the people who other doctors have said are not good surgical candidates. They have only a couple of months to live, and are told, “You should get your things in order.”

Campbell’s case isn’t like this, however. “He’s pretty vibrant,” Poa says. “He walks every day. He is not what we consider high-risk.”

By the late 1990s, the technique was becoming more accepted, and Poa studied under the big names until he became a mentor himself. He’s been doing off-pump surgeries since 1996 and tallies nearly 300.

The previous night, Poa, as he usually does, ran through Campbell’s operation mentally. Heart surgery, like fixing anything, can be somewhat repetitive. But if a mistake is made, “it snowballs.” When an excellent surgeon gets into trouble, “that surgery does not look any different from a normal surgery. If everyone else in the room feels like it’s a crisis situation, they will not act the same.

“I will be thinking about the worst-case scenario in every surgery,” Poa says.

“I treat each patient as family. I have never gone with the genre of trying not to make it personal. I do make it personal.”

Less than an hour after we talk, Campbell is out cold, his skin sterilized with iodine in the center of a room full of stainless-steel clamps, monitoring equipment and people in scrubs and masks.

At first, there’s just the quiet puffing and beeping of machines as the surgery gets underway.

While Poa focuses on the patient’s sternum, Physician’s Assistant Shari Knutson is harvesting veins from Campbell’s leg, which will be meticulously measured and cleaned before being grafted to bypass the “bad” veins in his heart. The relatively new technique of endoscopy means the veins can be retrieved through inch-long slits in the leg, rather than long cuts that require about 90 stitches and a more painful and longer healing time. Fiberoptics—the tube glows like a Halloween light stick—allows Knutson to monitor the process on a television screen.

Poa has requested an Andrea Bocelli CD, and the Italian tenor’s plush voice contrasts oddly with the buzz of the cauterizer sealing off blood vessels. The smells of burning and antiseptic dominate the sterile room.

Suddenly Poa starts introducing people: “Everyone in the room has a lot of heart experience.” At his side is Dr. Roger Stringer, a semi-retired cardiac surgeon whom Poa recruited to come to Chico.

“The team is very crucial. Everybody plays an equal part pretty much,” Poa says.

With beating-heart surgery, the organ moving around isn’t the biggest problem: “You kind of get used to it. The difficult issue was the positioning of the heart,” Poa says. Demonstrating how quickly technology advances, Poa mentions that “the first generation of these stabilizers was just a fork.” From 1996-98, devices pushed the heart inward to stabilize it. Since 1998, the trend has been away from compression and toward suction-type stabilizers that cause less impact to the heart. “You try to be gentle with the heart, and you try to coax it a bit,” Poa says.

Matt Morris, a sales representative from Ethicon, the company that’s asked Poa to try out its heart-stabilizing device, steps onto a platform to see it placed into the patient’s chest. “As soon as I got it, they said, ‘Who are you going to target with this thing, and I said Dr. Poa,” Morris says of the retractor and associated equipment.

At 3:20 in the afternoon, well before the two hours he allowed for the operation are up, Poa announces, “At this point I’ll be closing.” Perfusionist Bob Hayes has, at Poa’s request, been timing how long it’s taken Poa to sew each of the two veins: seven and eight minutes.

Robin St. Clare, a cardiovascular liaison nurse, has been keeping Campbell’s family updated. “They’re fine. I make them fine,” she says. Once the surgery is complete, Campbell will be awakened almost immediately and likely get up and walk a bit within two hours. He’ll go home two days later.

The following Monday, Bernard Campbell reports from his Chico home, "I’m doing fine." His wife says his leg hurts more than his chest, unless "if he has to cough and move about." But he’s alive. And they’re happy.