• November 23, 1992
• Vol. 38
• No. 21

A Heart Stopper

By Giovanna Breu

A Radical New Surgery Saves Lives, but It's...a Heart Stopper

ON THE OPERATING TABLE, WHERE SHE has already spent five hours, Nancy Loiacono takes the slow, deliberate breaths of the heavily sedated. Nurses, anesthesiologists and surgeons hover over her, their every movement carefully choreographed. Tubes drip, monitors beep and the amplified sound of Loiacono's heartbeat fills the room. Then, in a scene familiar to fans of a full generation of medical melodramas, the heartbeat slows, the patient's life signs ebb, the lines on the monitor go flat. [P] But this is not television, this is real life, right at the cutting edge of medicine, and the flat line is just what brain surgeon Robert Solomon has been waiting for. Now that Nancy Loiacono has entered a near-death state, her heart stopped, her temperature 30 degrees below normal, Solomon can proceed with lifesaving surgery on an aneurysm that lurks just behind her left eye. [P] Circulatory-arrest surgery, perfected three years ago, reduces the risk of hemorrhaging during particularly delicate operations on the brain. The low body temperature also slows metabolism to 10 percent of its normal rate. Thus, the cells in vital organs, which begin to die almost immediately when blood stops circulating, remain undamaged for up to 60 minutes. Says Solomon: "Aneurysms that would have been inoperable before can now be cured with relative safety." [P] The chain of events that took Loiacono, 37, to this netherworld somewhere between life and death began last January, when she began getting headaches. "I was so sick," she says, "that my doctor admitted me to the hospital. I was delirious for days, crying and throwing up." A skull X ray and other routine tests revealed nothing. She was given antibiotics, and a doctor wanted to prescribe tranquilizers. "He thought I was just stressed out," says Loiacono, who is separated from her husband and lives in Lake Grove, Long Island, N.Y., with her daughters, Gina, 11, and Cynthia, 9. The headaches stopped—for three weeks. Then they started up again. [P] During the next four months, Loiacono was diagnosed with everything from malformed sinuses to migraines. But the mystery wasn't solved until June, when a magnetic resonance image, a powerful diagnostic tool that can provide a detailed, computer-created map of the brain, was taken of Loiacono's head. The MRI detected an aneurysm—a blood-filled bubble in an artery caused by a potentially lethal weak spot in its walls—in the carotid artery on the left side of her brain. It was the size of a Ping-Pong ball. [P] Then, at long last, Nancy Loiacono got a break: She was referred to Dr. Robert Solomon, 38, at Columbia-Presbyterian Medical Center in New York City—one of the nation's leading brain surgeons. Because of the size of the aneurysm and the difficulty he knew he would have in reaching it, Solomon told her he needed to perform circulatory-arrest surgery. Loiacono was actually relieved. "It was something that could be fixed," she says. "Yet every now and then I would cry because of the kids. I was really scared that something would happen to me." [P] When Solomon came by for a visit at 8 P.M. the night before her scheduled surgery, she was shocked to see he was still working. "Go home and get some rest," she told him. "You're operating on me tomorrow." [P] The eight-hour procedure, which eventually will involve six doctors and nine other health professionals, begins promptly at 7 the following morning, when Loiacono is wheeled into the operating room and given anesthesia. Her last conscious thought: "I don't want to experience any more pain. I will wake up and feel so good." [P] 8 A.M.: Two IV lines to provide blood, fluid and drugs are inserted into veins in Loiacono's arms, and a catheter to monitor blood pressure is inserted into her wrist artery. Another catheter is snaked from the jugular vein through the heart into her pulmonary artery. Squiggly red, yellow and blue lines on TV monitors track the beat-to-beat performance of her heart. "All these monitors keep us out of trouble," says anesthesiologist William Young. [P] 9:25 A.M.: Solomon and his staff begin to expose the brain by drilling a five-inch wide circular "trapdoor" in Nancy's skull. "This is just the primary opening," he says, his commentary directed to a visitor's gallery that includes several foreign neurosurgeons and neurology residents of the hospital. A microscope is swung into place over the opening. [P] 11:15 A.M.: It is time for heart surgeon Craig Smith to begin lowering Loiacono's temperature. He places two tubes in the groin area. One carries Loiacono's blood to a heart-lung machine, where it is chilled; the other returns the blood to her body. [P] 11:30 A.M.: As Nancy's temperature drops, conversation in the operating room falls off and then gives way to the amplified beat of her heart. [P] 11:42 A.M.: Nancy's heart begins to fibrillate. "It loses its normal rhythm and wiggles like a bag of worms," says Smith. [P] Noon: The heart stops beating. The blue, yellow, red and green lines that display her heart and brain activity flatten out. The cooling continues. "We're at 18° [64.4°F|, so we are ready anytime, Bob," Smith tells Solomon. [P] Smith cuts off the pump and begins draining five pints—nearly half of Loiacono's blood—to relieve pressure in the circulatory system. As he drains, the bluish mass that is Nancy's aneurysm collapses like a deflated balloon. [P] 12:07 P.M.: Solomon begins to operate. "When I am working on an aneurysm," he will say later, "I become so focused on what I am doing that I kind of lose touch with everything." The procedure involves using tiny spring-loaded steel clips to pinch off the neck of the aneurysm, while maintaining the free passage of blood through the artery. [P] Solomon installs five of the clips to seal off the broad neck of the aneurysm. They will remain in Nancy's head for the rest of her life. He also snips off the dome of the aneurysm to take pressure off the optic nerve. Then, like a plumber testing his work, he calls for blood to be returned to the circulatory system. "It's still not perfect," says Solomon, as the artery springs a tiny leak. He repositions one clip. This time the artery holds. [P] 12:35 P.M.: "I think you can start rewarming," Solomon says. [P] "Rewarming," a nurse acknowledges, as Nancy's blood is passed through the warming cycle of the heart-lung machine. [P] "I think it's going to be OK," Solomon says to the crowded room. [P] 12:40 P.M.: Nancy's heart begins to beat spontaneously. As the sound of the heartbeat once again fills the room, the team relaxes and conversation resumes. [P] Solomon stands aside to watch his neurosurgery assistants finish the operation and allow himself a moment to reflect on what he has just accomplished—his 31st such operation since 1989. He looks exhausted. "Aneurysm surgery is like defusing a time bomb," he says. "The biggest fear is that aneurysms can rupture, and the bleeding could be fatal. You are always living on the edge." Two patients have died from complications during surgery. [P] June 25: Thirty-six hours after her operation, Nancy Loiacono is recovering in her hospital room. To her disappointment, her head still hurts. "I am sick of suffering," she says. "I can't wait to feel better. [P] After a week, Nancy is released and goes to live for nine days with her mother in Plainview, Long Island, N.Y. Then she moves to her sister's house in Commack, Long Island, where her daughters have been staying since she was hospitalized. [P] July 30: Nancy is finally at home with her daughters. Her headaches have stopped. She has started driving again and has resumed her studies toward a computer systems degree at a community college. "It really feels so great not to have those headaches anymore," says Loiacono. "I literally put my life in Dr. Solomon's hands. He really cared, and when I think about it—oh, my God—I'm so glad." [P] And her sense of humor is coming back. At the supermarket, she absentmindedly bags some groceries without paying for them. "Excuse me," she says to the checkout clerk. "I just had brain surgery." [P]