This device allows the operator of the heart-lung machine to put medicines directly into the blood. © University of Wisconsin-Madison Medical School, Edward Joseph, photographer.

From this point on, every minute counts. Heart-lung machines may make the operation possible, but "on the heart-lung machine," the perfusionist (defined) explains, "bad things happen to blood." When red blood cells contact the foreign materials in the heart-lung machine, they are damaged. That's important. Red cells undertake the blood's number-one responsibility: ferrying oxygen to virtually every tissue in the body. But it's not just red blood cells that cause problems, he adds: "There is a list of 20 things that can go wrong, the longer you pump, the worse you are."

Still, haste may be important, but technical perfection is the goal. And nobody expects to finish in the 68 minutes on bypass that Yeltsin's surgeons just achieved.

Eager to simplify this complex, expensive operation, some surgeons have tested various methods for operating without the heart-lung machine. In other words, working on a beating heart. Sound tricky? You bet. Yet it's been done about 1,700 times, according to the Heart Surgery Forum.

A new study compares a bypass technique that bypasses the bypass machine (in other words, does not use the heart-lung machine). But we'll guide you there later if you want to continue reading here. Here's a comparison of bypass with balloon angioplasty. That's where they put a balloon into your artery and expand it to push the plaque to the side so blood can get through.

10:37 Bluish blood from the veins enters the heart-lung tubing. Had Smith not been receiving heparin, a drug derived from beef lungs that interferes with clotting, his blood would congeal immediately in the heart-lung machine. The anti-clotting drug is just one of many subsidiary but essential tools and techniques that allows this extremely invasive surgery to be performed with a national average death rate of less than four percent. For relatively healthy patients in the hands of surgical teams that do many surgeries each year, the mortality rate is under one percent, according to Rodman Starke, senior vice-president for science and medicine of the American Heart Association.

Other tools include the specialized instrument to spread the chest, clamp the aorta, and cut and sew delicate veins and arteries. Today, in fact, Love is expecting some high-end surgical tools, but the Federal Express plane did not land on schedule, and he's disappointed. "The instruments are on the plane, the check is in the mail, I'm from the government and I'm here to help...I've heard that before," he moans. Does it seem that this chief surgeon was chosen more for his senses of humor than his many years of training and experience? Perhaps -- but humor cuts the tension.

Love asks about pressures in the various tubes to the heart-lung machine, checking that the valve between the aorta and the left ventricle is closed. If the heart fills with blood, it could expand and damage delicate, overstrained muscle cells.

Pressure is also on the anesthesiologist's mind: An examination of Smith's face and eyes ensures that the output of the heart-lung machine is being shared by the head and body, and is not going solely to the head. That kind of thing can happen, and it's extremely dangerous.

10:50 "The aorta clamp is on," Love announces. With the aorta clamped, Smith is entirely dependent on the heart-lung machine -- his heart has stopped beating. The aorta clamp is a cumbersome affair, a 16-inch stainless-steel pliers, it's S-shaped and designed so it can snake into the body without entangling the various wires, tubes, stitches, hands, scalpels and scissors passing in and out of the opening in the chest.

Still, it's sticking up awkwardly on this patient. In jest, Love urges an assistant, "Stick that clamp under the door and bend it back."

10:51 "Give cardioplegia." With this command, Love directs the team to start pumping a cold solution of potassium and blood into the heart. This solution cools the heart to help it survive surgery better. More important, the potassium solution will cancel out the nervous signals that have directed this heart to beat roughly 90 times a minute for the last 60-odd years. After approximately 2.5 billion beats, this heart is going to stop. Temporarily.

10:54 The resident has finished stitching up the leg. He bandages it, and recovers it.

Now all the action will center on the heart.

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