The publishing house "Bomborra" published a book by cardiac surgeon Stephen Westaby, "Fragile Lives." In it, he talks about his most complex operations. Life around publishes excerpts from the chapter "Black Banana" - about a successful heart operation on a six-month-old girl.
Call to Australia
Monday, January 15, 1999, at a quarter to four in the morning. No one calls at night with good news. I was in Australia only 13 hours after a 24-hour flight. In total darkness, I crawled to the other end of the bed and, trying to grab the handset, threw it to the floor. The call has dropped. I immediately fell into a dream again - thanks to the melatonin pills and the Merlot bottle sentenced for dinner. Ten minutes later, the phone rang again. This time I managed the phone, but was very annoyed.
"Westby? This is Archer. Where are you?"
Nick Archer was a senior pediatrician in Oxford.
"Nick, damn you, you know perfectly well that I'm in Australia. You woke me up in the middle of a fucking night - what happened?"
Honestly, I didn’t want him to answer.
"Sorry, Steve, but we need you here. We have a sick child here with AOLKA (abnormal discharge of the left coronary artery from the pulmonary artery. - Approx. Auth.). Parents know you and want you to operate it. "
"As soon as possible. The girl has heart failure, and we are doing our best to maintain her in a stable state. There is trouble with the ventricle."
Further conversation continued there was no point. I had already clearly imagined the frightened parents who desperately wanted to save their child before it was too late, as well as two grandmothers and two grandfathers on duty at his crib, wanting to help, but in reality only adding fuel to the fire with their emotions.
"Well, I'll fly today. Tell mine that we will operate it tomorrow, well, or what day you will have there."
Kirsty was a wonderful six-month-old girl in whom, by the will of fate, a self-destruction mechanism was instituted: a tiny defect, which would seem to doom her to death before her first birthday. AOLKA is an abbreviation meaning abnormal discharge of the left coronary artery from the pulmonary artery, an incredibly rare congenital pathology.
In simple terms, this is the wrong connection of the arteries. Both coronary arteries should exit the aorta, saturating the heart muscle with oxygen-rich blood under high pressure. They should in no case be attached to the pulmonary arteries, since this simultaneously reduces pressure and reduces the concentration of oxygen in the blood supplying the heart. Thus, the survival of a newborn with AOLKA depends on the formation of new “collateral” blood vessels between the normal right coronary artery and the displaced left coronary artery. Ultimately, however, they are not enough for normal blood supply to the left ventricle. Deprived of access to oxygen, the cells of muscle tissue die off and are replaced by scar tissue, due to which the child, in fact, suffers from repeated painful heart attacks over and over again. Scars are stretched, due to which the left ventricle increases in size, the heart gradually weakens, and the lungs are full of blood, which leads to severe shortness of breath and fatigue. Even while feeding.
Thus, at six months old, Kirsty had the same problem as my grandfather - heart failure due to the final stage of coronary heart disease. Since the disease is incredibly rare, the diagnosis is most often made even when the child cannot be saved.
Preparation for surgery
When I got to Oxford, I called my colleague Katsumat and asked him to bring Kirsty's parents to my office, not forgetting to capture the standard form of informed consent. Heart catheterization showed exactly what Archer suspected. Kirsty was in urgent need of emergency surgery.
When I first saw her mother Becky, she looked tired and haggard. She immediately guessed who I was. Her face lit up when they were in my office in a cold modular office.
“We are so glad to see you,” she said. “How did you get there?”
“Good. Quietly,” I lied. “So, we need to get down to business, right?”
Katsumata got an electric heater somewhere in order to somehow warm the room, and we sat down to discuss everything. They explained to me that one of their relatives was a representative of a company producing artificial heart valves and knew me well. He was supposed to see me initially at a meeting planned in Australia. They expressed regret for my trip that failed, and also many thanks for returning, as they would not allow anyone else to operate on their baby. So, they were enthusiastic, but Becky could not calm her trembling because of the greatest fear. Poor thing. After so many weeks of waiting in the hospital, the time has finally come - the day has come when she can lose her baby.
Usually I do everything so as not to get infected with anxiety. My fellow anesthetists, however, are harder in this regard: they have to deal with a painful separation when their parents hand them small patients. I described to my team the operation I had planned and explained why, in my opinion, this would be a significant improvement in the existing technique. I was going to concoct a new left coronary artery from a part of the aortic wall, placing it below the corresponding section in the pulmonary artery to form a tube, at the top of which will be the displaced beginning of the existing left coronary artery. The result should have been a new coronary artery, which would deliver to the heart well oxygenated blood under high pressure directly from the aorta, from which it was originally supposed to depart. Blood rich in oxygen will provide the necessary nourishment to the muscles of a failed heart, preventing further mini-heart attacks. Katsumata was intrigued and thrilled by the approach I proposed and even ran to assemble a hospital crew.
Since the girl had very severe heart failure, the operation was associated with very significant risks. With a shaking hand, Becky signed the informed consent form, and with them I went into the orphanage. When we got to Kirsty’s crib, her condition was worse than I expected. In fact, I have never seen a small child so bad. She was skinny, practically without a single trace of body fat, her ribs with a noticeable effort rose and fell, and she often breathed - a consequence of stagnation in the lungs. From the accumulated fluid, her stomach was swollen. She was still a wonderful child, but without urgent surgical intervention she could not last even a week. Strongly cursing mentally, I only said out loud: "Now I’ll go to the operating room."
Mike and the nurses were actively preparing drugs and catheters in the anesthetic room. He knew what was happening, since Kirsty had already anesthetized before cardiac catheterization, and some of the monitors were still connected.
"Do you really think you can save the child?" he said to me on the move.
I didn’t answer, instead I began to weigh the friendly “good morning” nurses and perfusionists in the operating room, and then went straight to the rest room. I did not want to witness how Becky leaves her child with completely strangers to her: it was always a painful moment for her parents.
When I returned, Kirsty was already on the operating table, covered with green surgical sheets that were held in place by a sticky plastic wrap. Only her bony tiny rib cage and bloated belly remained in sight. Heart surgery should be an anonymous procedure, a matter of technology.
I joined Katsumata and my two-meter colleague Matthew at the sink for disinfection before surgery. While we were treating our hands with antiseptic solution in silence, a video camera was installed next to the operating lamps. An atmosphere of exciting excitement reigned around. We had to do something completely innovative, mysterious and risky.
When I ran a scalpel blade along Christie's sternum, she did not come out and a drop of blood. She was in a state of shock, and the capillaries in her skin closed to redirect blood to vital organs. Following the electrocoagulator cut through the thinnest layer of adipose tissue to get to the bone itself. This was accompanied by a characteristic buzz and burnt smell, as the current cauterized blood vessels, although this time almost nothing oozed from them. Then an electric saw walked along her sternum, exposing a red bone marrow.
With the help of a small metal retractor, we opened its tiny rib cage, bending and stretching the joints between the ribs and spine. In infants, the meaty thymus gland lies directly between the sternum and the pericardial sac - it has already done its job, providing the fetus with the necessary antibodies, so we safely removed it.
The electrocoagulator continued its dirty but vital work, cutting the pericardial bag so that we could reach the heart, - a pale yellow liquid poured from the inside, which was immediately eliminated by suction. Meanwhile, the rest of the operating staff was working in complete silence. Mike injected heparin to prevent blood clots in the heart-lung machine, perfusionists plugged in their numerous tubes, pumps, and equipment to saturate blood and tissue with oxygen to keep Kirsty alive while her heart was working and operating room nurse Paulina focused on so that at the right moment instantly give me the necessary surgical instruments. I rarely had to ask for something out loud. For such a coordinated work, it is necessary that all the people taking part in it be professionals in their field and have time to work together, and since most of those who were in the operating room have been in my team for many years, I completely trusted them.
When we parted the edges of the pericardial sac to expose the heart, Katsumata inhaled loudly and muttered, “Oh shit.” The sight was really intimidating. Returning after his first smoke break, Mike bowed his head over the sheets, intrigued by Katsumat's comment. I agreed that in reality everything turned out to be even worse than we expected. Everyone else saw it on the video screen.
The heart, which was supposed to be no bigger than a walnut, in fact turned out to be the size of a lemon. The swollen right coronary artery immediately rushed into the eyes, the numerous dilated branches of which sought to reach the left ventricle. While the right side of the heart actively pumped blood, trying to withstand increased pressure in the lungs, the left ventricle was very relaxed and almost did not move. Strips of necrotic muscle tissue interspersed with patches of white fibrous tissue of the pericardial sac - this was the result of the many painful micro-infarctions that Kirsty had to endure in the first six months of her life. Katsumat's fears were quite appropriate, but I did not respond to his comments. Our task was to achieve normal blood supply to the heart, so that it would feel better. Kirsty was still alive, and we should have worked hard to keep it that way.
Having laid bare her heart, I began to doubt how wise it was on my part to get involved in such a complex operation immediately after a daily flight from the other side of the globe. On the other hand, would it be better to postpone the operation or completely abandon it?
Kirsty had no other choice. It was almost impossible to find a donor infant heart for transplantation urgently, so the planned redevelopment of the vessels supplying her heart with blood was her only chance of salvation. Together with the video camera, the Old Woman Death watched what was happening in a languid expectation, and we all understood this very well, but now there was no turning back.
We connected it to the heart-lung machine with thin tubes, and I gave the go-ahead to get it started. The perfusionist started the pump, and Kirsty's heart was gradually empty. The machine took over his work, redirecting blood from the lungs to the chamber to artificially saturate it with oxygen. The bloodless heart continued to pulsate, and I cut the pulmonary artery above the branch from the pathological left coronary artery. Here was the beginning of a blood vessel. Our task was to connect it, without creating excess tension in the tissues, with the aorta located a couple of centimeters above. The traditional method was simply to try to stretch and transplant the beginning of the coronary artery laterally onto the aorta. The problem with this approach was that it often led to thrombosis and blockage of the artery, so I continued to follow my plan.
To do this delicate work, it was necessary to squeeze the aorta with a clamp, temporarily depriving the heart of blood supply. To protect the heart muscle, we injected a cardioplegic solution into it directly through both coronary arteries, which caused all the blood to go away and the ventricles to deflate, like a punctured soccer ball. During heart operations, his activity often has to be stopped in this way, and to return everything as it was, you just need to remove the clamp from the aorta, allowing the blood from the AIC to re-fill the coronary arteries.
To restore such a tiny blood vessel, it is necessary to impose precise, neat and completely tight seams. It worked out pretty well for me. Just half an hour after Kirsty’s heart was stopped, we managed to give Kirsty’s left coronary artery its proper form. When we removed the clamp from the aorta, bright red oxygenated blood flowed into the left ventricle - instead of oxygen-deprived blood with a blue tint, which he had to be content with for so long. The color of the heart changed from pale pink to deep purple, and then it became almost black places. Before we started restoring the pulmonary artery, we checked the stitches behind it for bleeding. Soon, an electrocardiogram showed uncoordinated electrical activity, and the heart contracted with newly acquired muscle tone.
After the restoration of blood supply, her heart continued to contract convulsively and randomly - she had ventricular fibrillation, which is quite unusual for such a small child. We applied the defibrillator directly to the muscle to restore normal heart rhythm. Ten joules - a discharge! Defibrillation was successful, and the heart stopped beating, as if in convulsions. Now it remained motionless, but we expected that normal heart rhythm was about to recover. Unfortunately, this did not happen. The purple ball began to shake again, and the anesthetist leaned over the girl to say the obvious: "Another discharge!" We did so, but the situation repeated itself. The heart did not start.
It was a serious violation of the electrical activity of the heart caused by an abundant amount of scar tissue, so we introduced special drugs to stabilize the membranes of muscle cells.
“Let's give him more time,” I told Mike.
"Well, I'll go have a smoke then," he replied.
Twenty minutes later we tried again. 20 joules - a discharge! This time, her whole little body bounced on the table, and fibrillation was stopped. Although her heart began to beat, the beats were too weak. A terrible sight, however, we had stocks of drugs to cheer him up a bit.
I asked Mike to start the adrenaline infusion, and I told the perfusionist to lower the AIK pump's power so that a little blood remained in my heart. This is the operational protocol in the operating room - just like in the army. When we need something from fellow doctors, we surgeons ask them to, while we give orders to the technical staff. If you begin to give orders to anesthetists, they will send to hell and go away to do something else.
While Mike, together with perfusionists, made sure that the biochemical composition of the blood was optimal, I did not take my eyes off Kirsty’s small touching heart. With her new coronary artery, everything was in order - she did not twist anywhere and did not bleed. For the first time, her left ventricle received oxygen-rich blood under the same pressure as the rest of her body. Meanwhile, her heart still resembled an overripe plum and almost did not beat. Moreover, the mitral valve was terribly leaking. Although I distinctly heard how I had just instructed myself to continue pumping blood for another half an hour, in fact, I thought that we were in a position that the heart could no longer be saved. The child was likely to be doomed to death.
Of course, I did not begin to share my thoughts with the rest. We have managed so many times to save hopeless children that they hoped that I would be able to help this girl. My own enthusiasm has already begun to fade. I asked the operator to stop shooting for a while, because no changes were expected in the near future, and asked Katsumat to take my place at the operating table so that I myself could rest a bit. I took off my surgical suit and gloves and went into anesthetic to make a call. Mike followed me.
"Can you tidy up the mitral valve?" he asked me.
“I don’t think so,” followed my reply. “I will ask Archer to warn his parents.”
I plopped down on a chair and picked up the handset. The kind nurse put coffee and a plate with a donut in front of me. Touching me with her hand, she felt cold sweat flowing down my neck.
“I will bring you a dry shirt,” she said.
Five minutes later, Archer went down from the outpatient clinic to the operating room.
"Thought you might have a problem. Can I help you with something?"
“Take a look at the echocardiogram,” I said. - The restored areas are in order, but the ventricles are too weak. Moreover, the mitral valve passes blood. With this frequency of contractions, we cannot do without an external pump. "
I had a full bladder, so I went to the restroom. When I returned, my brain again took control of what was happening (now nothing else distracted him), and I just needed to concentrate as much as possible. Could I do anything to fix it? Good ideas were coming to an end.
The left ventricle was covered with connective tissue, it was expanded, and now also in the form of a ball, not an ellipse, as it should be in a healthy heart. From such a skew, the mitral valve opened and could not close on its own. While the left ventricle was diligently trying to pump blood through the body, more than half of it flowed back to the lungs. Heart function during surgery is always temporarily worsened, but in the case of Kirsty, everything was completely bad. I could only hope that the heart would come to its senses, having a rest, while the heart-lung machine was working. This did not happen.
The last chance
I returned to the operating room, washed my hands again and switched places with Katsumata. He did not say anything, but he looked obviously despondent - everything was clear without words. I asked Mike to start ventilating my lungs and told perfusiologists to prepare for a gradual shutdown of the device. Now Kirsty's heart had to take the blood circulation upon herself, otherwise she had to die right on the operating table. We all looked at the screen of her heart rate monitor, hoping to see her blood pressure rise. It briefly reached half of its normal value, but then quickly fell when the pump was finally shut off.
"Reconnect?" Katsumata asked.
Watching the left ventricle flutter on the screen of the echocardiograph, the perfusionist expressed doubt about whether it was worth it. In fact, he asked: "She can no longer be saved, right?"
Meanwhile, I was not yet ready to give up completely. Our failure would mean the death of this little girl and universal grief for her parents.
“Let's plug it in again and hold it for another half hour.”
This was already in itself a dubious undertaking, since long-term connection to the AIC always reduces the chances of success.
Kirsty's parents were waiting for news in the children's room - Archer had already gone to warn them. When we called him back, Becky insisted on coming with him to the operating room doors. It is impossible to describe how the mother feels in such circumstances. I understood only one thing - very soon, she could have the exhausted and lifeless body of her child in her arms. Should I tell her that the girl’s heart suffered too much damage, that the diagnosis should have been made a few months ago, and Kirsty was let down by our overloaded health system?
In those very rare cases, when a child died on the operating table, I always talked personally with my parents after the operation. I was always afraid of this - perhaps this was the worst thing in my work.
Returning from another smoke break, Mike said: “Nothing has changed. Can we turn off the machine?”
"No, I'm going to try something else. Turn off the lung ventilation. Turn on the camera."
That was our last hope. To justify what I was going to do, I could not do without invoking the laws of physics: never before had anyone done anything like this with a child. The pressure on the wall of the exhausted left ventricle of Kirsty was increased due to the increased size of the cavity. Recently, at a conference, I learned that a Brazilian surgeon performed a series of heart reduction operations for people with heart failure resulting from a tropical infection - Chagas disease - that weakens the heart muscle. Other patients with heart failure in North America have also tried this operation, but this approach has been subjected to great criticism and was soon abandoned. It seemed to me that this bold technique could save Kirsty's life.
I was not going to take the risk and stop my heart again, so I took a brand new shiny scalpel and cut the beating left ventricle from the base to the top, as if unzipping the sleeping bag. I started with a section of scar tissue, trying not to touch the mitral valve-supporting muscles, and the girl’s heart immediately responded to such a radical intervention with fibrillation. This was not a particular problem, since there was no risk of air entering the bloodstream.
Honestly, I was stunned by the unexpected appearance of the inner surface of the heart. From the inside, it was covered with a dense layer of white connective tissue. To reduce the diameter of the ventricle, I cut out strips of tissue on either side of the incision I made, until I got to the bleeding muscle, eventually removing a good third of the ventricle. I tried to solve the problem with the mitral valve, stitching together two of its petals in the center, turning its hole from an oval into a double, in shape resembling glasses. Then I simply stitched the edges of the muscle together with a double stitch and closed my heart. Ultimately, this greatly reduced heart looked like a twitching black banana. Not for a moment did I believe that it would ever start up again; neither of my colleagues believed in it. Most of them decided that I started.
Rumors of a strange operation in the fifth operating room quickly crept around the hospital. Gawkers gathered around, and the operator continued to shoot everything. We had to make sure that all the air came out of the heart, otherwise it could then enter the bloodstream, reach the brain and cause a stroke. Finally, it only remained to start the defibrillator and try to restore normal heart rhythm.
“That's it,” I announced. “Try 20 joules.”
Discharge! The heart stopped fluttering, and, for ages, it seemed that its normal electrical activity did not want to resume - usually this happens spontaneously. I poked my heart muscle with forceps and it contracted in response. This time, a surge appeared on the cardiomonitor. By some miracle, this black banana threw blood into the aorta.
Mike looked back at the echocardiograph monitor. "It definitely looks different. Let's try with a pacemaker?"
I already sewed thin wires of a pacemaker. We set 100 beats per minute on the pacemaker and started it. I asked the perfusiologist to slow down the pump and leave some blood in my heart to check if it would pump it. This time the heart did not disappoint. Moreover, judging by the echocardiogram, the mitral valve no longer allowed to leak. At that moment, I felt that we still have a chance. Our life really depends on the laws of physics and geometry.
It was already after noon. Kirsty was connected to the heart-lung machine for more than three hours in a row, and it was time for us to disconnect it. As if by order, her own heart rate began to break through the pacemaker signal. Naturally coordinated heart rate is much more effective than that generated by pacing: it gives much more blood flow and pressure.
We seemed to have clicked in the operating switch. The gloomy atmosphere gave way to enthusiastic glee. Adrenaline was thrown into my bloodstream, and suddenly there was no trace of fatigue left. We gave Kirsty adrenaline to help her heart cope with blood circulation after turning off the device. Finally, I instructed to "slowly turn it off." We still feared that blood pressure would decline, but her small heart, with its new, funky shape, continued to pump blood hard.
"AIK is disabled. I can't believe my eyes," Mike said.
I didn’t say anything, but I looked over the mask at Katsumata. He knew that I already had enough.
“Let me finish,” he suggested.
Not believing my eyes, I cast a last look at the hard-working little black banana, and then turned to the screen of the echocardiograph - the white, black and blue flashes on the monitor that were completely inaudible for the average person also inspired confidence. It was seen how blood passes through the left coronary artery, and a double stream enters the left ventricle under pressure through the mitral valve - in front of us was a child’s heart of an unimaginable shape, which now finally worked.
After our meeting at the operating room door, Archer and the girl's parents were sure that Kirsty was dead. The situation was awkward and unprecedented, but I was too squeezed out to deal with it. I asked the anesthetist nurse to call Mr. Archer back to the pager operating room. She complied with my request, and then offered to bring coffee.
After making sure that no blood was leaking anywhere, Katsumata carefully closed his chest.
“No one has done this before,” he said, looking up at me. Shortly afterwards, Becky came to the intensive care unit in a nursing home in shock. She took Kirsty’s tiny foot in her hand and exclaimed: "She is warm. She has never been so warm." When she started to cry, I left. It has been a very long day.
Christie is now 18, and she is a cheerful teenager who loves sports, but if she had died then, we would never have known that the heart is capable of such an amazing regeneration. Perhaps her case will still help save countless lives in the future.
Cover: LLC "LitRes"