It did worry Lillehei that this would be one of the first examples of an operation during which someone who didn’t need surgery would be put at risk—this was shortly before the first living-donor kidney transplant in the United States was attempted—and for which the risk to the donor was unclear. The donor would simply have a small incision on his upper leg, with a catheter placed in his femoral artery and femoral vein. After the procedure, these vessels would be repaired and the wound closed. But heparin would need to be given to prevent clotting of the circuit. At any point in the procedure, the lines could become dislodged, leading to bleeding. Also, the donor would be exposed to whatever infection the “recipient” might have—but these were all babies or young children, so Lillehei hoped that risk was low. Perhaps the biggest risk would be the potential for air to get into the circuit. He and his team would need to be vigilant.
In March 1954, Lillehei identified his first patient, Gregory Glidden, a one-year-old boy with a loud heart murmur and an enlarged heart. By the time Lillehei looked at Gregory’s angiogram, it was clear that the child had a VSD and didn’t have much time left. Lillehei told Gregory’s parents, Lyman and Frances, about his plans. He would need to check their blood types, and if they were a match, he would hook one of them up to Gregory in the OR. He was clear that there were no guarantees, and that he had never done this before on a human being. The parents agreed immediately; they would do anything to save their son.
After Gregory was asleep, they opened his chest and looked at his heart. Everything was a go. They placed a cannula in his aorta and one in his superior vena cava. The boy’s father, Lyman, was wheeled into the room, groggy but awake. He looked over at his son, and Lillehei told him everything looked good. They put Lyman to sleep and then cut down into his thigh to expose his vessels. Once everything was hooked up, and all the lines were examined, Lillehei gave the signal: “Pump on.” The small roller pump whirred to life, and blood flowed through the lines. There was no leaking. Lillehei placed tourniquets on the inferior and superior vena cava and pulmonary artery and cinched them down. Gregory’s heart continued to beat, but it was not getting any blood. Lillehei cut into the ventricle. When he got inside, there was still bleeding, more than he expected, but they could keep up with it with suction. Lillehei carefully and accurately sewed up the defect with interrupted sutures. He then filled the heart with saline to get rid of the air and closed the wall. As he released the tourniquets, he asked for the time: fifteen minutes and twenty seconds. They had done it!
Sadly, the intraoperative success was not matched with a good outcome. Gregory did great at first, but then became infected with postoperative pneumonia. Despite heroic efforts from Lillehei and his team, they lost him on post-op day eleven. Lillehei convinced the child’s parents to let him do an autopsy, during which he was at least happy to see that his repair was intact.
Lillehei pushed on with cross-circulation. He performed a total of forty-five operations; twenty-eight of these children survived. The rest died, a reality that hung heavily on him. Still, he persisted. Whenever he did have a death, he always told the family himself—not something all cardiac surgeons did in those days. While at first he limited the surgery to VSDs, as he got more comfortable, he became the first person to correct more complex congenital anomalies, including a tetralogy of Fallot and an atrioventricular canal, heart defects whose repair required significant effort and a lot of imagination, given that no one else in the world had ever repaired them.
Maybe the most dramatic case of the series was the first tetralogy Lillehei fixed. The boy, a ten-year-old, had blood type AB, which no one in his family shared. The Red Cross went through its records and identified Howard Holtz, a twenty-nine-year-old highway worker and father of three. They approached him to see if he would be willing to save a young boy he’d never met. Holtz agreed. “I just wanted to do what I hope someone would do if my child were a blue baby.” The operation was a success.
Also among Lillehei’s cases was one disaster. A young woman, Geraldine Thompson, was to serve as the “pump” for her eight-year-old daughter, Leslie, who was dying from a VSD. After Leslie’s chest was opened and the surgeons were getting ready to operate on Geraldine, an IV running into Leslie for her anesthesia inadvertently got filled with air and pumped a major air embolus into Geraldine’s brain. The mistake was recognized and the surgery aborted. Lillehei closed Leslie’s chest without fixing her defect, and she died a few years later from her VSD. As for Geraldine, she lived the remainder of her life severely disabled, requiring a long-term care facility (although she lived to the age of eighty-eight). Even though Lillehei himself hadn’t made the error, he felt responsible, and he urged the family to sue him to help with the costs of Geraldine’s care. (They did—and lost the suit.)
Lillehei presented his results at a few major conferences, with mixed responses. At this point the only person in the world performing open-heart surgery, he was treated like a hero by some in the field, but others found him entirely unethical. True, he didn’t know what the exact risk was for his “donors”; then again, neither had Murray or Hume or others when they’d started doing transplants. There were no other options for their patients, and with his operation, Lillehei gave them a better-than-50-percent chance of survival. Who among us wouldn’t have jumped at the chance to save our baby or young child if given this option?
Back to Philly, 1952
“I believe we are approaching the time when extracorporeal blood circuits of the heart-lung type can be safely employed in the treatment of human patients.” This is what Jack Gibbon said at the annual meeting of the American Association for Thoracic Surgery. By this point, Gibbon and his team had achieved great success with their optimized Gibbon-IBM machine. They had performed numerous successful pump runs on dogs, where the team put the dogs on bypass and opened either the right atrium or the even more challenging right ventricle. They had explored the valves, and had caused and repaired injuries throughout the heart. They had performed multiple runs up to thirty minutes, thought to be of sufficient time to fix the majority of defects they were aware of at that time, and the dogs had woken up and been fine.
Gibbon’s first attempt at full cardiopulmonary bypass in a human was in February 1952 at the Pennsylvania Hospital. The patient was a fifteen-month-old girl, extremely ill, weighing eleven pounds, most of which was water weight from fluid overload. The preoperative diagnosis was a large ASD based on examination, but cardiac catheterization was unsuccessful, likely due to the child’s size. Gibbon took her to the OR and placed her on his machine. The heart was severely enlarged and beating poorly. When he opened her right atrium, he found no ASD. He closed the heart back up, but it couldn’t take over and liberate her from the machine. She died on the table. The autopsy showed in fact a different diagnosis: a patent ductus arteriosus, a congenital abnormality outside the heart, which could have been fixed in those days without a bypass machine. Who knows if the girl would have survived if this had been known preoperatively.
The following year, in May 1953, Gibbon treated Cecilia Bavolek, an eighteen-year-old in her first year of college. When she was a baby, her parents were told she might have a heart defect, based on the presence of a murmur, but she thrived and needed no treatment. She started to become ill at the age of fifteen, and over the next three years she was in and out of the hospital with shortness of breath, fatigue, fluid overload, and related symptoms. She was ultimately diagnosed with a likely ASD, although VSD remained a possibility. Gibbon agreed with the diagnosis, and Cecilia was taken to the OR and placed on full bypass. Gibbon opened her swollen heart through her right atrium, and indeed encountered an ASD. He explored her ventricle and found no defect. He carefully sewed up her atrium, and then closed her heart. The machine had served as Cecilia’s heart and lungs for twenty-six minutes.
That July, Gibbon attempted two more cases, both five-year-old girls. The first one was correctly diagnosed with an ASD, but her heart was so weak that after repairing
it, Gibbon could not get her off the bypass pump. After trying for four hours, he gave up, and she died. When he opened the heart of the next little girl, he indeed found an ASD, but there was also a VSD and a patent ductus arteriosus. He attempted to close the defects, but the bleeding was too severe, and she bled out on the table.
That was it for Gibbon; he was done. He declared a moratorium on his use of the machine and never returned to heart surgery. This was shocking to the heart surgeons of that era. How could someone who had spent more than twenty years working on this machine, who was about to summit his Everest, just walk away at the relatively young age of forty-nine? And given that he did, without doing the heavy lifting of moving bypass from a conceptual success to a clinical reality, does he deserve credit as the father of cardiopulmonary bypass, much less of open-heart surgery?
Gibbon continued as chairman of surgery at Jefferson, doing thoracic and abdominal surgery until retiring at the age of sixty-three. He had many other interests, including poetry, painting, travel, and of course his beloved family. He left the development of the cardiopulmonary bypass pump and open-heart surgery to others—primarily Lillehei, and John Kirklin at the Mayo Clinic. Kirklin had visited Gibbon in 1952 and was interested in making his own version of the pump. Gibbon had the blueprints sent to Mayo, and with the help of engineers from IBM and Mayo, updates were included in a version of the machine made there. Kirklin pushed forward, reporting his own somewhat successful trial of eight patients in 1955. Four of the eight survived.
By this point, Lillehei could see that cross-circulation would ultimately be abandoned once bypass became more predictable. He hated the complexity of the machine, and the cost. Then, in 1954, Richard DeWall, who had joined his team, set out to design a simpler, cheaper bypass machine. His strategy for oxygenating the blood was to create a reservoir for blood where oxygen was bubbled in at the bottom. It was simple and efficient. Lillehei used this machine successfully for the first time in May 1955.
Also that year, the great Willem Kolff got into the bypass game. When Kolff was working on his kidney dialysis machine, he had recognized that the blood seemed to become a lighter red as it ran through his sausage casings. It occurred to him that perhaps if he surrounded his membranes with high-pressure oxygen, this would diffuse across the membrane and oxygenate the blood. Once he was at Cleveland, he worked with others there to perfect this device, to be called a membrane oxygenator.
Over the next decade, more and more heart surgeons obtained machines using these three techniques, and got better and better at operating them. A version of the Minnesota machine was marketed for as little as a hundred dollars, compared to thousands for the more complex Gibbon version. Although each version had success, over time the membrane oxygenator won out. Regardless, these three machines and the efforts of these men made open-heart surgery a reality. By the end of the 1950s, open-heart surgery was commonplace, and increasingly complex surgeries were being attempted. How much further could the field go?
7
Hearts on Fire
Making Heart Transplant a Reality
Our greatest glory is not in never falling, but in rising every time we fall.
— CONFUCIUS
For a dying man, it is not a difficult decision [to accept a heart transplant] because he knows he is at the end. If a lion chases you to the bank of a river filled with crocodiles, you will leap into the water convinced you have a chance to swim to the other side. But you would never accept such odds if there were no lion.
— CHRISTIAAN BARNARD, ONE LIFE
October 2006
It started with some pain and numbness in her right arm. It didn’t seem like a big deal at first; it probably was related to her busy day: the long walk, the house cleaning, and of course the never-ending tasks that come with a new baby. Tina had just had her son (her third child) two months before, and maybe she had pushed things a bit. Still, something just didn’t seem right, and although she couldn’t quite put her finger on it, she kept trying to get an image out of her mind: her three children without their mother.
When she woke up in the middle of the night, her illness was undeniable. She still had the arm pain, and now she was experiencing nausea and diarrhea. Her husband called an ambulance—he wasn’t going to take any chances—and after a little time in the hospital, Tina felt much better. The nurse told her that as soon as her last blood test came back, she could go home. That sounded good. She almost felt embarrassed that she’d come to the hospital in the first place, for a little arm pain and an upset stomach. Then the nurse came back to the room and told her there was some news. Her blood test, that last one they’d done, had come back abnormal. It indicated that Tina had suffered a heart attack. What? She hadn’t had any chest pain, had always been healthy, and had never smoked. There must have been a mistake. They told her they needed to transfer her to a bigger hospital, in Lacrosse. After making some calls to her family, she was packed up into another ambulance and whisked out the door.
After she was settled in a room in Lacrosse, she told the nurse there she had to go to the bathroom. She distinctly remembers getting up, again feeling like something was wrong—and then she collapsed. She was in the throes of another major heart attack. Things got a bit hazy after that. She was told she was brought back to life twice. She remembers waking up to see her family gathered around her bed looking worried. She remembers being flown in a helicopter to Madison, and two nurses holding her hand.
Things progressed very quickly for Tina. She was diagnosed with peripartum cardiomyopathy, or PPCM, a rare disease in which, during pregnancy, a woman’s heart gets stretched and becomes dilated. The muscle weakens, which leads to symptoms of heart failure, including leg swelling, shortness of breath, fatigue, stroke, and even heart attack. The surgeons placed an LVAD, or left ventricular assist device (that is, a mechanical pump implanted into the left ventricle), in her heart. The device was hooked to wires that came out of her belly and connected to battery packs, which Tina ultimately would carry around in a backpack.
Tina spent about a month in the hospital, but with the help of the LVAD, she was able to recover. Before she was discharged, doctors taught her how to take care of the LVAD: how to change the batteries, how to hand-pump the device if the batteries ran out. She was sure that would never happen to her.
But it did, and she ended up back at Madison. Somehow Tina hung in there, with a failing heart and a new baby. She had been placed on the heart transplant list and needed to get a heart before another event killed her or the LVAD became infected. It was a race against the clock, but she made the best of it, despite sleeping most of the day and night.
“Even at a year and a half, my son knew that no matter when we left the house, he’d grab that pack of all the batteries,” she said. Tina was on the waiting list for fourteen months. Toward the end of that time, she got an infection of her LVAD, which was life-threatening but also moved her up the list.
On the morning of December 5, Tina’s phone rang. She was getting her kids ready for school. It was seven o’clock in the morning, with a heavy snowstorm outside. She wasn’t expecting a call that early and was surprised by a voice she didn’t know. It was one of the coordinators at the cardiac program at the University of Wisconsin: They had a heart for her. Was she ready?
She felt the mix of exhilaration and guilt that all our patients experience. They wait so long for that call, hoping against hope that it will come before it’s too late. At the same time, they know they are waiting for someone else’s death, someone they will never meet but to whom they will be connected in a more intimate way than their parents, children, or lovers—and for the rest of their lives. Tina remembers looking outside and noting that the blizzard would make the long drive to Madison treacherous.
As it turned out, this same blizzard, the biggest of the year, is what had killed Katie. She was just twenty-four and had four children under the age of six. Driving a car, Katie took a curve at just the wrong time. A snowplow was
coming the other way. A car driving behind the oncoming plow slid out of its lane, colliding with Katie’s car. The only good to come out of this tragedy was that Katie had actually just talked to her mother a couple of nights before about her wish to be an organ donor if she died. She hadn’t had time to sign up for it yet, and it had certainly never occurred to her that doing so was an urgent matter. That desire would turn out to be a gift to her mother and to Tina.
Tina had been so strong throughout the fourteen months on the waiting list, always staying positive, but she finally broke down when she was being wheeled to the holding area of the operating room right before the surgery. She started to think about dying, about her family—and about the donor. Her surgeon, Dr. Takushi Kohmoto, held her hand and, in his calm and quiet way, told her everything would be okay.
Her surgery was long, complicated by the LVAD that had been in there for over a year. Still, everything went well, and Tina’s recovery was as smooth as could be. She was out of the hospital in less than a week. And since that time, she has been entirely healthy. She has been a mother to her three children, including her little boy, who is not that little anymore. She calls him her “little miracle” because the cardiomyopathy that resulted from the pregnancy connected her to the miracle of heart transplant. And what a miracle it is. Patients come in and get this simple operation, and it turns their life from a living hell to a normal existence overnight.
“I cherish every day. I mean, I’ve always been a positive, upbeat person,” she says, adding that she is definitely more so now. “I’m thankful,” she says. “I don’t get upset over little things . . . I just cherish everything I have.” And with her oldest child getting married in October, she says, “I get to be here to see that.” Tina has seen pictures of Katie, her heart’s previous owner, and has gotten to know Katie’s mother. She is Facebook friends with Katie’s children, and hopes someday to meet them. She knows the relationship with Katie’s family has been healing for her and hopes the same is true for them. She celebrates Katie’s birthday every year, almost as if it were her own.
How Death Becomes Life Page 12