How do you mend a broken heart?

• Author: Bailey, David
• Position: Heart bypass operations at Duke University Medical Center - Focus on Health Care; includes related articles - Cover Story

Amid a background of pale-blue surgical drapes, the operating-room light glints off the stainless steel of the chest divider. Between its jaws, down inside the smooth, glistening white sack called the pericardium, the patient's heart sloshes around like a load of clothes in a washing machine.

Although the heart is the color of an uncooked chicken breast, the two clear plastic tubes that snake across the room to the heart-lung bypass machine are as red as a child's wagon. The machine cools the blood to 89 degrees and infuses it with oxygen so the body will never know that the heart has been shut down for 40 minutes while a surgeon reroutes a few arteries.

After a paralyzing dose of potassium, the zigzag on the monitor's screen suddenly flattens out, and the heart quivers to a standstill. Cradling it in his gloved hands, Dr. Robert Jones gingerly probes the coronary arteries with his forefinger.

"Lot of biscuits," the Duke University professor of surgery says.

As a resident begins the intricate process of placing eight stitches in a vein the size of a pencil lead, Jones says, "The number of these Phil's done is less than 100. The number I've done is in the thousands. So my experience helps his young hands. - Jones, 50, had the same sort of help as a resident in 1969, when surgeons here performed the first heart-bypass operation in North Carolina. He came to Duke because it was possibly the best place in the nation to learn heart surgery. More cardiologists and heart surgeons are trained here than anywhere else in the country. In the past 22 years, more than 10,000 bypasses have been performed at Duke University Medical Center. Stopping a heart, patching it and starting it again has become about as routine as an appendectomy.

It's a routine that generates millions, money that makes a big difference to the bottom line. Cardiovascular procedures are among the most profitable in medicine, and Duke administrators estimate that heart care will contribute a fifth of the medical center's net revenue of $449 million for fiscal 1992.

In fact, Duke Medical Center has evolved into what could be called Cardiac Inc. - a plant where the raw material is heart disease and where the product is measured in the number of years patients can add to their lives by having their hearts repaired.

Cardiac Inc. helped its department of surgery get more money from the National Institutes of Health in 1990 than any other department in the nation - $9.2 million.

This plant also enjoys surging demand because it sits right on top of one of the world's best markets for heart care. An estimated 68 million Americans have some form of heart disease. And for a variety of reasons, Southerners have far more than the average. Though state-by-state figures for heart disease are not available, the death toll is: North Carolina ranks 10th in fatal heart attacks; South Carolina is No. 1.

"In the old days, we could only treat patients for the complications of a heart attack and hope they would survive," Duke cardiologist Thomas Wall says. "However, today with clot-dissolving medication and on-the-spot intervention with angioplasty or bypass surgery, we can reduce the risk of dying from 25% to 50%."

Heart attacks, caused by constriction of the arteries that feed the heart muscle, once killed half of those who had them before they got to the hospital. Now, because of better ambulance service and emergency treatment, two out of three survive. Blue Cross and Blue Shield of North Carolina calculates that the per capita expenditure for the treatment of heart disease has tripled since 1983.

Even at 82, Jones' biscuit eater is fairly typical of Duke's bypass-surgery patients. He was referred there from another hospital, had suffered significant damage to his heart muscle and was a high-risk case.

Jones does bypass surgery on 250 or so patients a year, two-thirds of them over 65. In the six months ended March 30,1990, Duke surgeons performed 443 bypasses, 90 more than at Wake Medical Center in Raleigh and 104 more than at Carolinas Medical Center in Charlotte. Duke's cases tend to be the most difficult because many are referred from other hospitals.

As Jones rolls over at 6 a.m. to turn off his alarm clock, an anesthesiologist is getting his patient ready to enter one of Duke's four operating rooms reserved for heart surgery. After downing an Ultra Slim-Fast milkshake and digesting the Durham Morning Herald, jones drives his '86 Toyota minivan 12 minutes from his lake-side home north of Durham to the hospital, arriving around 7.

After visiting three patients he had worked on the day before, he heads for the operating room. While he scrubs, surgical assistant Maureen Maseda removes 12 inches of blood vessel from the old man's leg. Phil Shadduck, the resident, is busy at the head of the table. From throat to diaphragm, he slices through the skin and muscle of the patient's chest, then picks up an electric saw and neatly cuts the breast-bone in two.

Now in his surgical scrubs, Jones watches an X-ray movie of the patient's heart, which resembles a misshapen, throbbing globe with rivers that branch into dozens of tributaries. He must memorize this tortuous map so he can go straight to the arteries that are narrowed. "It's like looking at someone's face," he says. "You have to remember what they look like because in the operating room you'll see only the surface of the heart."

At 8 sharp, Jones re-enters the O.R...