March 4, 2009| A commitment to ensuring the best possible results for his heart patients has led UAMS’ Gareth Tobler, M.D., to multiple surgical firsts in Arkansas.

Tobler, a cardiothoracic surgeon, has embraced some of the very latest techniques and is working in concert with cardiologists on behalf of patients at the University of Arkansas for Medical Sciences.

Stapler Replaces Sutures
Tobler recently became the first heart surgeon in Arkansas to perform an entire bypass surgery without the traditional use of sutures to attach arteries and veins. Instead, he used a stapler.

“A stapler has been developed that you can load the vein onto, insert the stapler into the artery and fire it like a regular stapler,” Tobler said. The result is a durable, uniform connection.

It’s also faster. And with heart surgery, the faster the better.

“Risk of infection, risk of bleeding and risk of damage to other organs is always reduced when you have a shorter operation,” Tobler said. 

Rare Hybrids
When a patient arrived at UAMS last fall with clogged coronary arteries, Tobler worked with a UAMS cardiologist, Behzad Molavi, M.D., to provide the first combination stent-bypass procedure. Molavi inserted stents to open two arteries and Tobler performed a bypass on one.

The so-called hybrid procedure was the best solution for the patient’s long-term health, both doctors said. Collaboration on a hybrid procedure between a heart surgeon and a cardiologist is rare anywhere, and it was a first for UAMS and apparently a first in Arkansas.

A stent is a wire mesh tube that holds arteries open to improve blood flow. A bypass involves rerouting blood around blocked arteries with other arteries or veins taken from various parts of the body. Patients with multiple clogged arteries don’t normally receive both. That’s typically the case even if a stent would be better than a bypass in one artery, and a bypass would be better than a stent for another artery.

Tobler’s and Molavi’s unprecedented hybrid is expected to become more customary at UAMS, said David Rutlen, M.D., director of the UAMS Division of Cardiovascular Medicine.

“Dr. Tobler and Dr. Molavi have demonstrated that this can be done very effectively, which gives us confidence that we can do the same for any patient in the future if the situation calls for it,” Rutlen said.

Keeping the Beat
Tobler also is among an elite group of surgeons in the United States who routinely perform bypass surgeries without stopping the heart. And he may be the only heart surgeon in Arkansas for whom the technique, called off-pump or beating heart surgery, is standard procedure. 

By performing bypass surgeries off-pump, Tobler avoids use of a heart-lung bypass machine, which redirects all blood from the body through the machine. 

“There are problems with it,” Tobler said of the conventional bypass machine. “You have to put big tubes in (the aorta), and you have to empty out the patient’s circulation, and you have to run it through a pump, and there are problems with a lot of different complications.”

In addition to speeding the surgical process and reducing a patient’s hospital stay, the beating heart technique lowers the risks for bleeding, infection, stroke and kidney failure.

Taken together, Tobler’s efforts and unique collaboration within UAMS give heart patients the best chance for an exceptional outcome.