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In 2012 the Emperor underwent off-pump coronary artery bypass surgery. Although a highly complex procedure, this method was chosen because it puts remarkably less physical strain on the patient. Doctor Hiroshi Niinami of the Saitama Medical University International Medical Center (located in the city of Hidaka, Saitama Prefecture) is one of the leading experts in this procedure, performing around two hundred of these operations every year. This procedure guarantees the heart an extra ten years of life compared to conventional methods, and Dr. Niinami intends to take improve it even further.
70% of Bypass Operations in Japan are Off-Pump
Why is it that “Japan is the most advanced country in the world for off-pump coronary bypass operations,” as Dr. Niinami declares?
There are three main methods of treating angina (when the coronary artery narrows) and heart attack (when the coronary artery is blocked): drug therapy, coronary artery catheterization or coronary artery bypass. A coronary artery bypass is performed in cases where attacks cannot be controlled by drugs, constriction in the coronary artery is difficult to reach with catheterization, there are risks associated with catheterization, or there is narrowing in more than one location. Another blood vessel is used as a graft to create a detour, or bypass, to restore blood circulation to normal. It used to be standard procedure to temporarily stop the heart and use a heart-lung machine, essentially a pump, to artificially perform the functions of the heart and lungs to circulate blood throughout the body while performing the bypass. However, in Japan 70% of these operations are now performed using the so-called off-pump method, which is performed with the heart still beating, using an instrument called a stabilizer to inhibit vibrations in the sections being sutured. The greatest merit of this procedure is that the physical strain on the patient’s heart and body is greatly reduced, leading to a faster postoperative recovery. Although heart-lung machines are extremely safe, it cannot be denied that stopping the heart and putting a patient into a state of suspended animation for a long period inflicts damage on their body.
Despite its Merits, the Off-Pump Method is Barely Used in the West
According to Dr. Niinami, “In America only 17% of all bypass operations are off-pump, and in Europe it is 10%.”
There are three reasons for this. One is that on-pump operations with a heart-lung machine are easier and thus more efficient. “Even young surgeons with limited experience can do them, and operations that take five hours off-pump can be completed in three hours on-pump. It lends itself to managing numbers.”
The second reason is that inexperienced surgeons who tackle off-pump surgery are lowering favorable outcomes. “Off-pump procedures are difficult for young surgeons who haven’t racked up experience with multiple operations, so it’s no wonder they don’t perform well with them. But even in the West, hospitals that specialize in off-pump surgery are getting fantastic results and outcomes.”
The third reason is that in Japan bypass surgery is only performed on the most severely affected patients. “In the UK, for example, the ratio of bypass surgery to catheterization is 1:3. Bypass surgery is performed on even mildly affected patients. In Japan the ratio is 1:14. There’s a tendency to perform catheterization as much as possible because reducing the strain on the patient is the number one priority. Then again, this means that those patients who undergo bypass surgery in Japan are in a much more serious condition than most of those in the UK. Because bypass surgery is chosen as the last resort for patients in a serious condition, who may be elderly or have other complications, it’s only natural that the safer off-pump procedure should be chosen.”
A focus on off-pump coronary bypass surgery is the outcome of giving a high priority to reducing physical strain on the patient and pursuing a high level of expertise.
Arteries Used Wherever Possible for Long-Lasting Hearts
Another outstanding characteristic of bypass surgery in Japan is that wherever possible, arteries are used to make the graft in bypass operations. The grafts used in bypass surgery are usually taken from a leg vein, the internal thoracic artery behind the sternum, a forearm artery, or the gastroepiploic artery. The leg vein is not very difficult to harvest, but the internal thoracic or stomach arteries are significantly harder. In addition to a certain degree of expert skill, it also takes about one hour just to harvest a graft. Nevertheless, arteries continue to be used because their vascular life is twice as long. Dr. Niinami explained. “Seventy percent of veins wear out within ten years, no matter how skillful the surgeon might have been. In comparison, arteries last for twenty years, because the coronary artery is an artery, not a vein. In my opinion, nature made veins to be used as veins. The blood pressure on veins is about 10 mmHg. Arteries, on the other hand, have 120 to 130 mmHg at the lowest. If a blood vessel in an elderly person has functioned as a vein for 70 years before suddenly being put to work as an artery, that’s a tough leap. At least, that’s how I see it.”
Yet Dr. Niinami doesn’t perform all coronary bypasses using arteries. “We use leg veins for patients over eighty who cannot endure a long operation. Some patients are satisfied with the prospect of another ten years, until they’re ninety – it’s enough. Every patient is treated on a case by case basis – my policy is to do what’s individually best for each person.
“The other day, when I was at an academic meeting in Germany, I asked why in Germany they only used one graft of internal thoracic artery at the most, and then only use veins. As I expected, the answer was that harvesting the internal thoracic artery is difficult. I was told that if a junior surgeon is given the job and accidentally destroys the vessel, it prolongs the surgery even further.
“So that’s the situation, even at a major heart specialist hospital in Germany. If the patient improves for a while, then that’s enough. Their attitude is that they can always do another operation if the vein wears out. Meanwhile we are basically aiming to avoid having to do another operation.”
Clinton was On-Pump,
the Emperor was Off-Pump
Japan is dotted with hospitals that perform only fifty to a hundred heart operations per year, whereas in the West there are centers that perform a thousand to two thousand in the same time period. The circumstances are so different it’s difficult to make a sweeping comparison, but in regard to bypass operations, it is likely that Japanese patients have an advantage in receiving off-pump surgery using arteries, even if the procedure takes twice as long as on-pump.
“Former U.S. president Bill Clinton is an example of someone who had bypass surgery on a heart-lung machine, with one graft taken from the internal thoracic artery and one from a vein. Even if there’s a greater chance more surgery will be required in the near future, veins are used like this in the West. In comparison, the Emperor was over eighty when he had his surgery, but he had off-pump surgery with artery grafts only. This is a common difference between Japan and advanced Western countries.”
Anesthetists Have no Opportunities to Demonstrate their Skills
One day in September, a man in his seventies was undergoing an off-pump coronary bypass operation in the cardiovascular operating theater at Saitama Medical University International Medical Center. It took two hours to prepare the vessels from the left and right internal thoracic arteries and the gastroepiploic artery.
“Using only the left and right internal thoracic arteries and the gastroepiploic artery – not leg veins – is characteristic of my bypass surgeries. There’s a knack to using the gastroepiploic artery, and only a few surgeons in Japan can do it, but it produces extremely good results.”
The cut in the chest was made in one stroke, extending a few centimeters and then cutting down.
“Suturing the blood vessels behind the heart is a particularly difficult part of the procedure. You put the needle into the heart and pull, and incline very slightly – it’s all done in a very confined space. If you could turn the heart over that’d make it much easier, but it’d make blood pressure drop suddenly.”
Just sewing together vessels 2 mm in diameter is a difficult enough feat, but this procedure is also performed off-pump with the heart moving, without using a heart-lung machine. The patient’s blood pressure is stabilized at 80 to 90 throughout the surgery.
“Drops in blood pressure and cardiac arrests happen as a matter of course for the average doctor during surgeries. But Dr. Niinami is too good – there’s never any chance for anesthetists to show off their skills,” said the anesthetist who attended Dr. Niinami’s operation.
In surgical operations, the surgeon is focused on manual skills, while supervision of the patient’s overall condition is the responsibility of the anesthetist. If an anesthetist has time on his or her hands, it can be taken as proof of the high level of the surgeons’ skill. Four hours after commencing, the operation finished without incident. The patient has had his heart restored to a healthy state.
Performing Over 300 Operations a Year Refines a Surgeon’s Skills
“I don’t try to be fast. I’m not concerned with what other doctors do, I aim to give patients an operation that restores them to health and helps them to live longer.”
Many patients are elderly and have other chronic problems such as diabetes or high blood pressure. As well as needing treatment for a vessel, many also have complications from valvular heart disease or arrhythmia. If saving lives is the only consideration, then fast, minimal surgery is enough. Dr. Niinami, however, is looking to the future, and the quality of life ten or twenty years after an operation. He works on the principle of pursuing the most thorough course possible within the limits of the patient’s physical endurance.
Every year he performs more than three hundred operations, close to two hundred of which are bypasses. He continues to perform more than ten times the number of operations of the average Japanese cardiac surgeon, because that is the world standard.
“When I studied in Australia, a minimum of two hundred a year was the norm. Some veterans even reached a thousand a year. I believe that if you don’t have the numbers under your belt, you can’t guarantee the quality of the surgery. Whenever I get back from a week overseas on business, I can’t help feeling my senses have become blunter when I grip the scalpel again. A surgeon can only mature and improve skills through repeated practice. It’s numbers that provide the quality.”
A Desire to Instantly Liberate Patients from Suffering
Dr. Niinami was inspired to become a cardiac surgeon by the television drama Shiroi Kyoto (The White Tower), which he watched as a high school student.
“Jiro Tamiya was really cool as Professor Zaizen,” he said with a laugh, “so I decided I wanted to be a surgeon at a big hospital. Professor Zaizen was a gastroenterologist surgeon, while I chose heart surgery. If I was a heart surgeon I use surgery to give patients instant relief from their suffering. That was a huge part of what made it worthwhile for me.”
His goal is to develop the Saitama Medical University International Medical Center into a facility that performs over 1,000 cardiac operations a year. To this end he is devoting himself to training dependable medical staff to help carry out the work.
“At the moment we have three other doctors at the hospital who can do heart surgery. All of them are promising young surgeons who want to reach the summit of this path, and were directly scouted and trained by me.
According to the World Health Organization, the risk from lifestyle related diseases such as obesity, high blood pressure and diabetes is on the rise globally, and of the illnesses caused by these, the fatality rate from cardiac disease is 48%, with 17 million people dying from it every year. It seems likely that more and more people from around the world will want to come to Japan for off-pump coronary bypass surgery to treat angina and heart attack. There’s no doubt that more and more of them will want their surgery performed by Dr. Niinami.
Doctor Hiroshi Niinami
Professor of Cardiovascular Surgery, Director of Medical Treatment, Saitama Medical University International Medical Center. Born in Kanagawa Prefecture in 1962. After graduating from Gunma University Faculty of Medicine he completed postgraduate studies at Tokyo Women’s Medical University, then studied at Wayne State University in the U.S.A. and the Royal North Shore Hospital in Australia. Upon returning to Japan he became a lecturer and assistant professor in cardiovascular surgery at Tokyo Women’s Medical University No. 2 Hospital (now Medical Center East) and at Juntendo University honed his skills as assistant professor under the prominent physician Dr. Atsushi Amano, who operated on the Emperor in 2012. In 2007 he took up his current position.
text / Hiromi Kihara photos / Satoru Naito