Neil Armstrong, the first man to walk on the moon, died in 2012 at age 82 after what should have been routine heart surgery. When nurses removed wires linked to a temporary pacemaker, he bled profusely into the membrane surrounding the heart. He died a week later.
The medical details, disclosed this week by The Times, have prompted questions from both doctors and readers. Did Mr. Armstrong need open-heart surgery in the first place? What went wrong, and why?
Here are some answers from leading heart surgeons.
Mr. Armstrong went to the hospital complaining of severe chest pain. Don’t people with chest pain from blocked arteries get stents to open them up?
It depends on what sort of blockage a person has, said Dr. Michael Mack, a heart surgeon at Baylor Scott & White The Heart Hospital — Plano.
Three major arteries feed blood into the heart. In Mr. Armstrong, the most important, the left anterior descending artery, was not blocked, according to records received by The Times. The other two, the circumflex and the right coronary artery, were blocked completely.
“You can’t put a stent in an artery that is completely occluded,” Dr. Mack said — at least, it could not have been done a few years ago. With advanced techniques, it can be done now by some expert surgeons.
Were there other options?
The blockages Mr. Armstrong had were probably not going to kill him, Dr. Mack said, but they do result in chest pain, also called angina. So treatment was not life-or-death; it was a quality-of-life issue. That raises questions about whether Mr. Armstrong should have been rushed into surgery.
There is an alternative to bypass surgery: medical therapy, which means trying to treat the condition with drugs. The medications that alleviate angina include nitrates that widen coronary arteries, beta blockers that slow the heart and calcium channel agonists, which also open arteries.
“If it was me, I would try medical therapy first, but it depends on how severe the pain is,” Dr. Mack said.
What is a temporary pacemaker, and why did Mr. Armstrong get one?
In open-heart surgery — whether to bypass a blocked artery or to insert a heart valve — surgeons usually stop the patient’s heart so they can work on it. A heart-lung machine temporarily substitutes for the heart’s functions.
To stop the heart, surgeons infuse an icy solution into it. But the cold can dampen the heart’s electrical circuitry, said Dr. Jonathan Haft, a heart surgeon at the University of Michigan. So when doctors try to wean patients off the heart-lung machine, the electrical circuits can be slow to recover and the heart may beat feebly, or not at all.
So when surgeons finish the operation, they almost always sew fine wires, not much thicker than a human hair, onto the surface of the heart. They thread the bright blue or orange wires through the chest wall and skin.
The wires are hooked to a box the size of a clunky, old-fashioned cellphone, which generates electrical impulses that control the heart’s rhythm.
Once the heart’s electrical system has recovered, a member of the medical staff gently tugs the wires. They are so fine that they almost always come right out; if they don’t, they are simply clipped at the skin’s surface and left in place.
No harm is done most of the time, as the heart’s own circuitry takes over. (Permanent pacemakers, which are not meant to come out, are placed inside the heart, Dr. Haft noted.)
What went wrong in Mr. Armstrong’s case?
Very occasionally, when a nurse or other staff member tugs on one of the pacemaker wires, it tears the heart surface and causes bleeding. That usually occurs because the wire was stitched on too tightly, or someone pulled too hard, Dr. Mack said.
At first there may be no sign of a problem, Dr. Haft said. But as bleeding continues, blood pressure drops and the heart rate rises. The condition, called tamponade, occurs because blood is pooling around the heart and starting to clot. This inhibits the heart’s ability to relax and fill with blood.
How often does this happen?
Extremely rarely, surgeons said. At the University of Michigan Hospital, which does thousands of open-heart surgeries annually, tamponade occurs once every several years, Dr. Haft said. It is so rare that medical staff may not look for it.
“You have to have a team that is prepared to look for it,” he said.
Do patients always die if wire removal causes bleeding?
No — it is very rare, surgeons said. Patients should be rushed to the operating room, where doctors stop the bleeding and suction out the clots around the patients’ hearts — or even use their hands to remove them.
But Mr. Armstrong was taken to a cardiac catheterization lab first, before he went to surgery. The cath lab, Dr. Haft said, “is not the solution.”
Doctors in a cath lab can put drains on a tiny catheter and try to remove some of the blood, but they will not be able stop the bleeding. Nor can they remove clots.
By the time Mr. Armstrong got to the operating room, his heart had stopped and he had brain damage from a lack of blood to his brain. He died without regaining consciousness.
Mr. Armstrong was treated at a community hospital, not a major medical center. Would that have made a difference?
“Of course I am biased, but in general I would say yes,” Dr. Mack said.
For the most part, bypass surgery is safe. But there are 1,150 cardiac surgery programs in the United States, he noted. Many perform fewer than 100, or even 50, bypass operations a year, while major medical centers may do several thousand. Outcomes are generally better there.
Dr. Mack said if he had to choose from among the roughly 40 hospitals that do open-heart surgery in the Dallas area, only six or seven would make the grade. “And I would pick the surgeon,” he added.
