Everyone in the room was silent. No one had heard of such a procedure.
One of the team asked, “Who else does something like this?”
“A surgeon in France named Dor. It is a new procedure, something others have not done. But I think the potential answer to heart failure may be changing the heart’s geometry. It is also likely, at the moment, this patient’s only chance.”
We began.
The team was understandably wary. Surgeons are always afraid to cut into a ventricle if it looks normal on the surface, because the stitches don’t hold well when you try to put it back together — since you are trying to make stitches in a muscle that’s squeezing.
But as we went forward, I explained that Dor’s solution to eliminate the tension from that area was by using a patch in the ventricle, to prevent the ventricle from tearing apart due to its torsion and twisting. It is similar to patching a tear in a rubber raft. If you were to try to fix the damage by scrunching up the rubber on either side of the tear and joining them together, it wouldn’t hold very well. But if you put a patch over the incision site, this takes all the tension off the tissues that remain in their normal position. Patches were not new to cardiac surgeons and were already used in a variety of operations, though never one like this.
The team fully engaged and followed every step. All went well with my inaugural procedure, and we restored the normal heart shape. (Figure 3)
The resulting heart motion told the functional story — as we observed the recovery of the twisting movement! There was immediate, remarkable relief from heart failure after the spherical ventricular chamber was returned to its more natural elliptical shape. Everyone around the table was mesmerized. I was ecstatic, and envisioned the tremendous potential for this procedure.
The memory of this success never fades, as I recall this initial operation each day in my office. At his three-month follow-up, the patient returned and gratefully presented me with a beautiful Royal Selangor Pewter Clock from Malaysia. It sits on the wall above the entry door to my office.
This gift’s intrinsic beauty of harmony and form wonderfully matched the new aura of self-assuredness that characterized the patient after my first case of ventricular restoration. Before surgery, the man was a shell of who he had once been. He felt like he was living on borrowed time. He was filled with anxiety and had little hope. After the procedure, he was a different person. His long-absent confidence, steadiness, and power had returned. He wasn’t dying. He wasn’t wallowing. He was a proud human being.
He continued to visit me periodically, always recalling the devastating experience during his bout with heart failure. He then described the bounty of symptom-free living that has followed our rebuilding of his ventricle. Remarkably, this reality is instantly observable when he enters my examining room, as his vitality and joy of living flow from him. This great gift made me appreciate the magnitude and beauty of Dor’s contribution to the world of congestive heart failure.
This patient’s operation would be the only such procedure I would do at this time. Nobody at UCLA sent me any cases like this, as no one understood what was occurring with heart failure, nor its association with ventricular volume. That is why I knew I had to build a team made up of the world’s top cardiac surgeons. Together, we could bring this to the world’s attention.
It was an adventure waiting for the right time. That time had arrived.
The Game Plan
In my office, I reviewed my 70 pages of ideas and strategies designed to document and validate this new game plan. I was pleased to see my thoughts were just as compelling now as they were during my impassioned airborne writing session.
It was clear that guidelines needed to be established for treating a region that was not typically approached by surgeons. Dor had shown that incising into such a normal-looking cardiac surface to exclude the underlying scar is a straightforward operation with proven benefit. My role now was to help accumulate data to make surgeons aware of this remarkable procedure.
Thus, the need for our study.
Replace… or Restore
Significantly, our study would finally present an alternative to the only other present surgical approaches for treating irreversible heart failure: heart transplants or insertion of mechanical devices. Rather than resolve a severely failing heart by subjecting the patient to a transplant from a donor, or having it taken over mechanically… why not use a far less aggressive procedure that fixes the heart that is already there by restoring its natural ventricular shape?
This alternative restoration would avoid the problems with transplantation (whose drugs can cause hardening of the arteries, kidney problems and cancer), or inserting heart assist devices (that can be accompanied by bleeding and clotting problems). I reasoned that bringing the heart’s function back to a more natural state was a better choice.
Opening Minds
Beyond educating surgeons about this approach, I knew another hurdle would be the role of cardiologists — as they are the gatekeepers who determine the course of treatment for patients. Cardiac surgeons won’t be sent patients whose ventricle they can restore, unless they are directed our way by cardiologists. For that to happen, we would need to show cardiologists why they should expand their focus beyond correcting the bulge (aneurysm) after a heart attack.
Yet at this point, no one except for Dor and Jatene (and once myself) had done this kind of surgery. In fact, just as this memoir reveals how new ideas frequently encounter resistance, Dor had already joined our endless cadre of innovators who experienced surgical opposition. His initial papers were rejected from publication in the American Association of Thoracic Surgery Journal (the leading publication in cardiac surgery). The journal’s reviewers could not conceive of cutting into a ventricle that had a normal, non-scarred surface. It was ridiculous from their point of view.
Their response reminded me of how Spanish leadership had tried to bar Christopher Columbus from his journey to the Americas, believing he would fall off the edge of a flat world. While the globe was actually spherical, these stalwarts of yesterday failed to explore for tomorrow.
Dor told me of this dilemma when I met with him, adding that abstracts for his presentations had also not been accepted for presentation at our annual AATS meeting. But I was so impressed by what he taught me, and with my own success in treating a heart failure patient, that I offered to help him rewrite his manuscript. I took on this task after speaking with our journal editor, John Waldhausen, who asked me to simultaneously write an editorial to accompany the Dor submission. They published Dor’s revised paper and my editorial together in the same issue.79 In my editorial, I suggested calling this rebuilding technique the “Dor Procedure” to honor his enormous contributions, and this is how it came to be known.87
But this early publication did not sway the medical community. Nor did I expect it would. It was just a first step toward changing the world’s perceptions of heart failure.
We Who Climb Do Not Climb Alone
As I was preparing the next stage for creating a new worldwide study toward solving heart failure, I recalled Julius Comroe at the CVRI in San Francisco, many years earlier, coming into our class of postdoctoral scholars one day while holding a drawing of a mountain. The image showed no evidence of a trail up its surface, yet a surgeon was conspicuously perched upon its peak after doing a heart transplantation.
Comroe began by saying, “I know you all want to be excellent — standouts in your field.” He then had us survey his picture as he asked us to describe why was it possible for this surgeon to stand so proudly on the mountaintop after doing a heart transplant. Had he performed some Olympian leap from the ground due to superhuman prowess?
“How did he get there?”
As we pondered what Comroe’s point might be, he turned the picture around to show us the back of the hill, strewn with boulders. “He did it by climbing upon the boulders carved by so many before him — whose numerous contributions made this possible through
X-rays, EKGs, antibiotics, blood transfusions, anti-rejection drugs, etc.”
“Nobody leaps to the top of the mountain,” Comroe continued. “You get there because you can step on these boulders that have been created for you, one after another, on your journey toward new ideas. What’s more, there will be times that someone else will be on the top of the mountain — helped by the boulders you provided for their ascent.”
His message was that it was never “me, me, me.” It was about the concept of the TEAM.
It was just such a team that I was about to form.
CHAPTER 17
Congestive Heart Failure: Enactment
Establishing a new clinical treatment for congestive heart failure by changing ventricular size and shape required that we establish a small team of outstanding international centers from the United States, Europe, Asia, and South America. Their collective task would be to see if they could repeat Dor’s results and improve the prognosis of heart failure patients using his method.
The “Magnificent Eleven”
I set out on a worldwide romp to meet with each of these handpicked physicians. I used my 70-page document to explain my plan to test this geometric concept in heart failure, and asked if they would participate. Contacting each beforehand, all I told them was, “I want four hours of your time to consider a whole new way of looking at heart failure.” I also emphasized that this trip was entirely at my own expense. I didn’t want any travel, hotel, or meal expenses provided. I just wanted their attention during this four-hour period.
Suitably intrigued, no one turned me down.
Each meeting took place in a different locale. I felt somewhat like the lead character in the original film of The Magnificent Seven, where Yul Brynner’s character travels to wherever he must to recruit the best people for his team. I met Francis Fontan, the leading surgeon in Europe, at the Hermitage Hotel in Monaco, in an empty ballroom far from everyone so we could concentrate. In Milan, I was picked up at a small airport by Lorenzo Menicanti and went to his home, where we drank Cuban rum and talked about the future of this treatment. Hisa Suma and I conferred in a luxurious Tokyo office building. I was with Sergio de Oliviera at his penthouse in Sao Paulo, Brazil. I ate with Fred Loop, the CEO of the Cleveland Clinic, in his elegant office, where my presentation would not be interrupted by anyone except for the private waiter who served us lunch. I also visited Nick Kouchoukos in St. Louis, Irv Kron at University of Virginia, Eric Rose at Columbia University, Connie Athanasuleas at University of Alabama, Friedhelm Beyersdorf from Germany, and of course, Vincent Dor of Monaco.
Engaging Discussion
I began each presentation by focusing on the fact that the heart attack region contained dead muscle. It did not contract when it bulged, nor when it shrank following angioplasty. The essential fact was that a scar formed after a heart attack, was treated by reperfusion, and was now hidden beneath the normal muscle on the cardiac surface. Yet the effect on the heart was not limited only to the scar that had replaced previously contracting muscle. It will also impact the “live remote muscle” that is now completely responsible for the heart function. This area stretches or dilates as it compensates, and this progressively impairs its performance.
Following this explanation, I introduced Dor’s novel surgical approach that excludes the dead scar and rebuilds the natural elliptical heart form, which will improve function of the remote muscle, and restore the heart’s ability to contract properly by twisting.
I knew I was presenting a unique challenge, because a surgeon would now have to take the unprecedented step of incising a normal heart surface to gain access to and exclude the underlying scar — and then do a new procedure that returned the heart’s shape to normal. Surgeons would be faced with an operation that none of them had ever performed before (except Menicanti, who was Dor’s student) — nor had ever heard of.
Yet these participants were undeterred because they had forward-thinking minds. Each was captivated by the possibility. They were not daunted by the task of incising the normal ventricular surface in order to reach the scar that lurked beneath. All of them knew there were ways to confirm that a scar was indeed present before cutting into the heart: by looking at the EKG to confirm the heart attack, viewing a ventriculogram to confirm the heart’s inability to contract, and by using commonly accessible isotope tests to verify the existence of a scar.
The use of these tests prevents the mistake of incising a normal heart surface, only to then find no underlying scar. Such an error could easily happen if one relies only on a heart’s inability to properly contract as an indicator, since limited or no contraction can also occur in non-scarred hearts if the blood supply is inadequate. You can imagine a surgeon’s anguish if they were to incise a ventricle in a critically ill heart failure patient — only to find there was no scar! Fortunately, these readily available safeguards prevent this mishap.
The joy of interacting with these very smart colleagues was dazzling, as each posed new questions and / or made innovative suggestions that expanded my knowledge. Though everyone was excited about what I presented, each also exercised their freedom to introduce divergent views. Part of why I’d selected these leaders was that I knew they would honestly tell me if they thought I was heading in a wrong direction — and why. I did not orchestrate these meetings to sell an idea, but rather to discuss and to discover, as well as to teach.
I certainly threw down a new gauntlet for our potential team, as these renowned leaders of cardiac surgery would not participate if this approach did not make sense to them. Yet the power of this new idea was infectious, as was their clear vision for the immense impact it might have.
Every one of them said yes!
Now numbering 11, our team was formed. Each agreed to a group meeting during the next American Association of Thoracic Surgery (AATS) conference in Boston.
The Path Forward
An open mind was the number one requirement I had for members of the team. This requirement transcended any stipulation that they be part of an academic university. Many of these distinguished colleagues had left the university system and established successful programs outside its walls. The spirit of inquisitiveness drove their never-ending pursuit to grow, and set the stage for creating better heart care.
I also hoped our initial work together might provide the underlying basis for developing an even grander future exploration. Success in reproducing Dor’s findings could motivate the National Institutes of Health (NIH) to sponsor a prospective randomized trial to study heart failure. Cardiologists and cardiac surgeons would work together toward a common goal. That is important, since cardiologists must accept that while their medications may help heart failure patients live longer, these drugs fail to alter the basic geometric reasons for impaired ventricular performance. This recognition opens the door to a new intervention of changing ventricular shape that will blend nicely with their drugs — to finally counter heart failure.
If successful, this joint effort could lead to a new treatment that would help an enormous pool of patients.
I made one additional request of team members. I realized that their prominence meant their status did not need further enhancement, so I suggested they each select a younger colleague to join us, whose career and reputation could blossom if this project was successful. I now could see a grand package evolving. A new idea, the development of an inclusive global view… and a baton being passed to a new generation of respected surgeons.
Vincent Dor of Monaco had recommended his outstanding student and colleague, Lorenzo Menicanti from Milan, whose fresh ideas became a breath of spring. I selected Connie Athanasuleas from Birmingham, Alabama, who had collaborated with me previously, was technically superb, had great capacity to make discoveries, and possessed an incredible aptitude for gathering insight by distilling knowledge from his comprehensive view of the medical literature.
A Change of Heart (Protection)
As it happened, visits to my future team members w
ere not the only trips I took during this time.
My belief in “traveling to learn” proved invaluable once more, following a visit to Randas Batista in South America. I saw him perform rebuilding procedures on a beating heart (cardioplegia was not used)! He was operating on big, dilated hearts caused by an infectious disease (there was no scar from a heart attack). But superb heart performance immediately followed his repairing these terminal ventricles, exceeding what I would expect from my blood cardioplegia approach.
I took a step back and thought, “This is really amazing!”
The flame of my curiosity beamed brightly, and I had to find out for myself if this approach would work. I went back to UCLA to test Batista’s heart protection approach in animal test subjects and had outstanding results. A unique turn of events, as I was now in a position of contradicting myself! Wow, my position had been to tell the whole world about blood cardioplegia, but now I would advocate for another technique — while heart shape is being rebuilt.
I have always been a seeker of truth, so my next step was to use this beating method during ventricular rebuilding in a patient with heart failure. Connie and I performed ventricular restoration procedures on a small number of extremely ill patients in Birmingham, Alabama, with Connie as the principal surgeon. The heart protection was excellent using this new technique, and each procedure was successful. My willingness to change thinking became based upon the evidence, and guided my adopting a new approach to protection.
First Collaborative Meeting
In anticipation of the upcoming gathering of our group in Boston, I had T-shirts made up to commemorate our first meeting. They displayed drawings I created that compared a dilated unhappy heart to a conical healthy one, (Figure 1) with the name of what I thought our group might be called emblazoned across the top.
Solving the Mysteries of Heart Disease Page 29