Politically Tough, but Surgically Simple

NEW YORK -- Sometime soon, a surgeon will gently press a scalpel into the chest of the president of Russia.

The blade will easily slit Boris Yeltsin's chest open, right down the middle, from one end of the breast bone to the other. Parting the skin and the fat layer below, it will create a valley of white with a few red patches of muscle.

No blood will gush from this wound. A few severed capillaries will bloom like tiny roses.

After the surgeon splits open the breast bone -- it takes about 10 seconds with a power saw that looks and sounds like a hand drill -- he'll be able to see his quarry. Covered with yellow fat, it will shift restlessly in Yeltsin's chest, right-left, right-left, right-left.

It's the most famous heart in the world, a marvelous pump with a plumbing problem. And the surgical team will set out to fix it. peer into the chest through magnifying lenses.

Some of the arteries that snake over the surface of Yeltsin's heart are plugged, choking off deliveries of blood to parts of his heart muscle. The solution: Create bypasses around the obstructions, attaching new vessels to act as detours for the nourishing blood.

For Dr. Alfred Culliford -- and for thousands of other doctors, in hospitals around the world -- this is routine surgery. And on an autumn morning, he and his colleagues at New York University Medical Center delve deep into the chest of a 72-year-old man to perform just such an operation, a triple bypass.

Before he can fix the heart, Culliford needs some spare parts from his patient to use as grafts. He finds one behind the ribs: the mammary artery, which normally carries blood toward the diaphragm and abdominal wall.

This artery is not irreplaceable. Other vessels could take over its job. Culliford cuts it and teases it loose from the ribs, leaving it attached to its source of blood. Then he lifts the loose end out of the chest and puts it on a sterile pad.

While Culliford works in the chest, another surgeon slits open the patient's left leg from ankle to groin and gently extracts another spare part: a vein, as long as the incision, that looks like a giant off-white earthworm. It is long enough to supply a couple of tubes, 152 millimeters to 203 millimeters long, for grafting to the heart.

As it happens, this vein is defective. The patient's right leg yields an acceptable one.

Now it is time to give the man's heart its first rest in 72 years, reducing the heart muscle's need for blood, helping it stay healthy when its blood supply is cut off for surgery.

Culliford inserts a clear plastic tube into the aorta -- the superhighway that carries all the blood away from the heart -- and another tube into the heart itself. When the heart-lung machine is turned on, blood drains from the heart tube, picks up oxygen in the machine, and flows back through the aorta tube so it can make its normal rounds of the body.

The heart pumps until still another tube injects a cold dose of potassium solution. Gradually the heartbeat grows weaker and slower. The spikes in the green line on the electronic heart monitor grow weaker and farther and farther apart, until the line flattens.

The heart collapses into the chest, no longer inflated by blood. The surgical team keeps pumping in cold fluid and pours ice-cold salt water over the heart from a stainless steel pitcher. The cold, like the rest period, cuts the heart's need for blood.

Now, more than two hours after the first cut in the patient's skin, it is time to install the bypasses.

The leg vein is cut into a pair of tubes. Then Culliford cuts a slit at each end of the tubes so that the ends flare out and flatten like a cobra's hood.

With a scalpel, he probes the heart's fat to find a place in one plugged artery downstream of the blockage. He gently cuts a 75-millimeter slit, which opens like a mouth about to speak.

With two tweezers -- as long as chopsticks, able to reach deep into the chest -- he begins to sew. He passes a curved needle, as tiny as a fingernail paring from a baby, through the edge of one of the vein sections and through the blocked artery near the slit. As he sews, the needle passes back and forth between his two tweezers, pulling a very fine filament.

Finally the tweezers pull on both ends of the filament, drawing one end of the tube down tight on top of the artery, the cobra hood fitting over the hole. Culliford ties about half a dozen knots in the filament, making each with a quick motion of his hands and pressing it down to the graft with his forefinger.

Now for the blood supply. Culliford punches a hole about one-fifth of an inch across in the empty aorta and sews the other end of the graft to it. The detour is complete.

He attaches the other graft to another artery and the aorta the same way. Finally, he sews the mammary artery to the third blocked heart artery. The triple bypass is complete. Now, it is time to back out of the chest.

With a shock from a pair of long-handled paddles, the heart beats normally again. The tubes from the heart-lung machine are taken out.

Culliford makes sure that his grafts aren't leaking, and watches for clots in the blood oozing into the chest cavity. His patient had been given blood thinner to keep his blood from clotting in the heart-lung machine, and clots now would show that another drug to counteract the thinner had taken effect.

"When you see clots, you can go home,'' observes Dr. Frank Spencer, chairman of the surgery department at the New York University School of Medicine.

Well, not quite. Culliford binds the breast bone back together with seven loops of stiff wire. And he sews up the skin incision.

Even after a successful bypass operation, doctors keep a close eye on the patient. Within the next 24 hours, dangerous bleeding could begin.

Or the heart, assaulted by the surgery, could abandon its pumping rhythm and start quivering like a dog shaking off water. This ventricular fibrillation could kill within five minutes if not treated.

In all, 30 to 40 things can go wrong after the patient leaves the operating room, Spencer says.

But he's optimistic about Yeltsin's chances. Judging from the reported comments of Dr. Michael DeBakey -- the renowned heart surgeon who has been consulted in Yeltsin's case -- Spencer said the Russian president's chances of recovery are around 95 to 98 percent.