Then I asked how the college footballer was doing. He was still wandering the corridors of the Texas Heart Institute, no longer in heart failure and building up muscle again. But still there was no donor. His girlfriend had gone back to college.
For me this evening was the calm before the storm. And Bud hoped it would be the beginning of a new era, one in which pumps would be used to treat patients who had no other option. Why should these medical life-savers be inextricably linked to transplantation? It was a waste of lifesaving technology, thousands of dollars thrown away when the transplant happened. I wondered what other historic discussions had taken place in the Eagle and Child over the centuries. This must have been the first about artificial hearts.
When the following morning came it was all a lot more relaxed than I’d expected. The pump company representatives sat chatting with Bud in the operating theatre coffee room. His technical assistant Tim Myers was already laying out the equipment with the nurses, who were excited but nervous, not wanting to screw up in front of their distinguished visitors. Abel came down from the ward with a procession of family and friends to see him off. Off to where, was the question. He sat slumped forward on the trolley in a white gown, head bowed, hands on his skinny knees, gasping for breath in anxiety. He just wanted to be put to sleep. When they passed me in the corridor he raised his head tentatively and murmured, ‘See you later.’ The man remained optimistic to the last.
This time I’d do the surgery, with Bud assisting and my colleague David Taggart joining us as second assistant. For such a politically charged event we managed to stay calm and business-like, almost to the point of levity. The pump’s manufacturer had realised that surgeons were not the brightest members of the medical profession so they’d put arrows on the titanium pump housing to make sure we implanted it in the correct orientation. I enjoyed making the gigantic incision from neck to umbilicus, never having been one for keyhole surgery, but while I was proud of my own abilities I was embarrassed by our outdated equipment. The old saw juddered up the breastbone, almost failing to reach the top. We made the pump pocket in the upper left abdominal wall, then zipped open the tense pericardium to expose Abel’s huge heart.
Like a baptism, I worked through the implant process step by step, doing it Bud’s way. Pipes in for cardiopulmonary bypass, next onto the heart–lung machine, empty Abel’s heart, then carefully sew the restraining cuff to the apex of the left ventricle and the vascular graft to the aorta. We cored out the disc of sick muscle from within the cuff and kept it for the microscope. Then in went the inflow cannula of the pump. Job done.
The critical last step was to remove all air from the system before the big switch on. We filled the heart by cutting back on the flow from the heart–lung machine. The left ventricle filled and blood entered the pump through the inflow. Air was pushed on into the vascular graft and expelled through a wide-bore needle. With the titanium ‘chocolate box’ sitting securely in its pocket, Tim was told to ‘switch on’. The noisy mechanism started up with its characteristic hissing noise and the last few bubbles fizzed out of the air needle. Abel had a powerful new left ventricle, one that you could hear across the street – but the patients get used to that, just like mechanical heart-valve patients get used to the tick, tick, ticking in the dead of night. It becomes part of bionic life and is much preferable to the alternative. Usually.
Abel woke quickly from the anaesthetic. Perhaps too quickly. He was immediately taken off the ventilator and his tracheal tube removed. I could tell that he felt different. He had a twinkle in his eye and a cheeky grin, and showed the relief and bewilderment that everyone has when they wake from an anaesthetic – the ‘I’m alive’ moment. All of his four limbs moved normally and he had no neurological issues. I felt like calling the chief executive – just as Christiaan Barnard had done after his landmark transplant – to say, ‘Sir, we’ve implanted an artificial heart and the patient is fine.’ But something told me to hold back and remain cautious for a change. This wasn’t about me, it was about getting Abel back on his feet again and I was worried that his blood pressure was too high. Rather than his own feeble left ventricle, he now had a powerful machine driving the circulation and was pouring out his own adrenaline in response to the unknown. The intensive care doctors needed to give him vasodilator drugs – and anticoagulation for his own heart’s abnormal rhythm – then sedate him for the night. The aftercare was as important as the surgery. I needed some sedation too, but overall it had been a great day.
No news is good news and I heard nothing overnight. Always on a tight schedule, Bud and the company men left for Heathrow early the following morning and I drove to the hospital at 7 am, filled with optimism and self-congratulation. I composed a press statement in my mind, fantasising about the headlines: ‘Oxford surgeon implants artificial heart’ or ‘Dying man saved by heroic surgery’. So I deserved the shit that hit me when I reached the bedside. I could see it in Abel’s face – that vacant look. He was drooling from the right side of his mouth, his eyelid drooped, and he didn’t greet me with enthusiasm and gratitude as I’d hoped. He couldn’t even lift his right arm or leg. He’d had a fucking stroke.
Every possible expletive ploughed through my cerebral cortex while the pump hissed at me. He was pink and warm, with great blood flow – but fucking paralysed. After everything had gone so well. Why had no one warned me? I instinctively wanted to blame someone else. But for what? My gut feeling was that he’d thrown off a blood clot – either from his own heart or from the foreign surfaces of the pump or vascular graft – in which case we should give him the rapid-acting anticoagulant heparin since the warfarin wouldn’t have had time to take effect. But a neurologist colleague persuaded me to do a head scan first, to document the extent of the brain damage and rule out a cerebral haemorrhage. If we gave heparin after a bleed into the brain it would surely prove fatal. But whatever the cause, this was a catastrophe, not least because of the financial implications of prolonged intensive care, all to be paid for by my research funds.
I accompanied Abel to the scanner. Bud and his team were already at Heathrow, unaware of the miserable development, and I was too pissed off to call them. Let them enjoy the flight back. I watched the scanner construct slices through the brain. The pathology was obvious but unexpected. There was bleeding into the brain. Not only that. The bleeding originated from an area of previous stroke that was definitely not recent, perhaps many months old. Why didn’t we know about that? It transpired that Abel’s wife had no knowledge of it either. He’d had headaches from time to time but had never suffered paralysis or weakness. Before now. So it must have been a ‘silent’ stroke, leaving us with the ‘devil versus the deep blue sea’ dilemma. Damned if you do, damned if you don’t. For now, Abel was disabled, but he wasn’t going to die. It was either ‘Think positive’, or get out of the high-risk business altogether.
I flicked the switch. Abel needed cardiac-and neuro-rehabilitation. Many strokes recovered with time and effort. He couldn’t swallow, so we needed to feed him through a gastrostomy tube. The gastroenterologists inserted this directly into his stomach through the abdominal wall. He couldn’t cough adequately, so he needed frequent chest physiotherapy. When he developed pneumonia, he had antibiotics. When he coughed so hard that he disrupted the skin around the drive line exit site, we revised it surgically. The physiotherapists worked hard to mobilise him. In three months the paralysis abated to weakness and the weakness resolved with exercise. Soon he was on the move again, rehabilitating himself. His speech returned, his swallowing improved and he restlessly wandered the hospital corridors, no longer breathless or swollen with fluid, no longer in heart failure. His life was returning, and so was my determination to press on.
From the sound of the pump and the hissing of the air vent – like a snake, but sixty times a minute – we always knew that Abel was close by before we saw him. It wasn’t easy for him to live with, but much, much better than breathlessness. One day I passed him while he was sitting out in a chai
r. He volunteered that he felt below par. When we persuaded him to get back into bed and attached him to the monitor we saw the reason for this. His own heart was in ventricular fibrillation, that uncontrolled rhythm that’s immediately fatal in an unsupported patient. Despite the fact that his right ventricle was now functionless, the left ventricular assist device kept him going. Incredible, I thought. Yet it happened on five separate occasions and we just defibrillated him each time. A quick sedative, apply the paddles and zap! – his own heart started again. In time we noticed another thing. His heart was shrinking and contracting more vigorously, replicating Bud’s finding that the dilated cardiomyopathy heart gets better with rest. It was important to find out why this happened on a molecular basis.
Had Abel died from stroke our charitable support could have died with him. As it was, he survived and was rehabilitated. The HeartMate continued to work well and we were close to discharging him from the hospital. Then the next patient was referred.
His name was Ralph Lawrence, and he’d taken early retirement from his job as a finance audit manager with Rover. He and his wife Jean liked to dance – folk dancing, barn dancing, ballroom dancing – energetic stuff, and they liked to travel around the country in their caravan.
Then in his early sixties, Ralph found himself increasingly breathless. The chest X-ray showed an enlarged heart, so his local hospital in Warwickshire referred him on to the heart failure clinic at the Royal Brompton Hospital, where Professor Poole-Wilson diagnosed dilated cardiomyopathy. The first step was treatment with heart failure drugs, followed by what was a new treatment in those days – electrical cardiac resynchronisation therapy with a special pacemaker. The aim was to better coordinate the contraction of different parts of his dilated heart to make the whole organ more efficient. But the beneficial effects can wear off as the heart gets bigger, and he was now in trouble again, severely symptomatic with a poor prognosis. Could he have a transplant? When Ralph was told that there was no chance of one at his age, strangely enough he accepted it, agreeing that scarce organs should go to younger people. He was a very likeable man with a supportive family, and we thought him an ideal candidate for the HeartMate.
While he was unable to do anything, Ralph was stable and not as sick as Abel Goodman had been. He had a few weeks to consider and reconsider the prospect, and we gave his family the HeartMate patient guidelines to look at. These were a daunting read, even for those who could anticipate a transplant in time. No swimming or baths. Showers, fine, as long as the electrical equipment was covered. Avoid tight clothing or dressings that might bend or kink the vent tube. Always have the emergency back-up equipment available. If the yellow spanner lights up on the controller it signifies malfunction. A red heart symbol with audio alert means loss of pump support, seek immediate assistance. And so on. This was all worrying stuff that Abel had had no time to consider.
I saw Ralph with Jean in my office in Oxford. They weren’t easily put off by the literature as by now his life was intolerable. There were no more outings, and he was sleeping propped up in a chair, ankles and feet too swollen for shoes, likely to die suddenly at any time. And the family knew that. I was concerned that he was an insulin-dependent diabetic, but he managed that well, being used to taking responsibility for his own health. He had a positive attitude and wished to proceed as quickly as possible.
‘So why not start today?’ I said. I thought they should arrange to meet Abel to ask him how he felt about life with the ‘alien’ inside him. I knew what his answer would be: ‘Better than heart failure. Better than being dead.’ And Jean needed as much knowledge of the HeartMate as her husband, as she might have to cope at home in an emergency, perhaps even work it manually for him during a power cut.
We agreed on a date for surgery, a Wednesday just four weeks away, giving us time to make arrangements with Houston. But on this occasion there was one more consideration. The grapevine had spread extensive awareness of Abel’s operation. Given his stroke we’d tried to stay low-profile, but because we were planning Ralph’s operation a month ahead it was inevitable that information would be leaked to the press. This was a two-edged sword. Public awareness helped me to raise the charitable money needed to maintain the programme but bad publicity in the event of the patient’s death could kill us. These debilitated heart failure patients would never be offered a hernia operation, yet alone heart surgery. So how to control the risk?
Between us we agreed that one newspaper should be given access to Ralph’s operation to avoid a media scrum. First and foremost, the family needed peace when – or if – he should leave hospital. The Sunday Times was the chosen route. They could have in-depth access to the whole undertaking, as long as the patient and family were treated discreetly. In return we’d be grateful if they’d consider a charitable donation. Not payment. But without charity, Ralph wouldn’t get his operation.
The night before the operation Ralph and Jean stayed together in a room provided by the hospital. Jean told the Sunday Times, ‘We were quite rested. He had come to terms with everything and was just happy that the operation was to go ahead.’ At 9.30 am on the Wednesday morning a sedated Ralph was taken by trolley to Theatre 5, once more unable to lie flat without gasping for breath. We hoped that he’d never again have that grim feeling of choking to death. This time there was huge interest within the hospital, so we agreed to video the operation and relay it to an auditorium. I was happy for the journalists and hospital managers to watch. In surgery we have a saying, ‘See one, do one, teach one.’ I’d seen one in Houston, done one in Oxford, but was quite sure that I was not about to let anyone else do Ralph’s operation under instruction. Bud and I waited quietly in the coffee room while the anaesthetist put Ralph to sleep.
It was 5 o’clock in the small, stuffy waiting room. All day, every day it was 5 o’clock because the clock had stopped long ago. Only the growing stack of empty polystyrene cups marked the slow passing of time. Jean sat waiting for news, poleaxed by hand-wringing anxiety. Then at 2 pm came the news that she’d been waiting for. Ralph was being wheeled back to intensive care.
On 12 May 1996 an X-ray of Ralph’s chest and artificial heart filled the whole front page of the Sunday Times Magazine. The caption read: ‘The man with two hearts – why a lump of titanium, polyester and plastic is ticking away inside Ralph Lawrence’. It was a risk to give a frontline national newspaper direct access to an artificial heart operation, with pictures from the operating theatre, and interviews with the family and staff. But they presented it extremely well and everyone could read it – the prime minister, members of parliament, even the Queen. The paper produced a pictorial, blow-by-blow account of the operation, which helped us sustain our laboratory research programme. Although we’d struck a chord with those who saw innovation as the duty of the NHS, we’d not done so with the NHS itself. This technology cost money and there’d be no support for it.
We always felt that it was Abel’s high blood pressure that caused the cerebral haemorrhage, so we kept Ralph profoundly unconscious for several hours. It was the middle of the night when he regained consciousness and Jean was sitting there by his bed, watching the visible action of the pump thudding away in his belly amid the paraphernalia of intensive care. Through the oxygen mask he said something to Jean. ‘You’re thirsty?’ she queried. ‘No. Is it Thursday?’ came the reply. Two days later Ralph was out of bed, sitting in a chair. The next day, Saturday, he was walking around the intensive care unit with the physiotherapist whose job it was to rehabilitate him.
Then disaster. As I was jogging through Blenheim Park my mobile rang. Abel was in great pain and suffering haemorrhagic shock on the ward, with acute bleeding around the pump. This had caused a huge swelling beneath his ribs, just at a time when his own heart had virtually recovered. We needed to remove the pump straight away and stop the bleeding, or he was going to die. I told them to call in the theatre team immediately.
I ran home faster than I should have done at my age and jumped into the
car. The roads were quieter at the weekend but I was pessimistic whether we’d get him opened up in time. Either we would or we wouldn’t – one had to remain sanguine, and an agitated, overexcited or anxious surgeon would never succeed in this predicament. I worked out what to do in the car. We’d never be able to reopen his chest quickly without causing damage, so I’d have to expose the artery and vein in his groin, cannulate both and begin cardiopulmonary bypass. Then he’d be safe. With enough transfused blood we could maintain flow to his brain and switch off the HeartMate. We managed to do this just in time, his blood pressure having fallen to half normal despite the transfusion.
I pulled the wires out of his sternum and ran the oscillating saw up the middle of the bone. As the edges parted, strips of shiny purple blood clot slithered through the gap and bright red blood spilled out from the lower end. I soon figured out that the change in Abel’s heart size had probably altered the position of the HeartMate inflow cannula and that this had sheared open the apex of the now smaller heart. My informed guess had turned out to be correct. As I dissected open the inflammatory mass I could see that the join between the vascular graft and the aorta was secure.
It was a straightforward decision. The pump had to come out. Either Abel’s own heart would succeed in supporting his circulation or he was dead. The easiest way to stop the inaccessible bleeding was to cool his body to 20°C, then stop the circulation altogether. In the meantime I amputated the HeartMate power line and discarded it, scooping out a mass of blood clot from the pump pocket in the abdominal wall. We were making progress, but I reflected that it wasn’t a great way to spend the weekend.
At first it came as a bitter blow to his family. They were looking forward to having him home after five months in hospital while he was in good form. Abel and Ralph’s wives were waiting together, one hoping for a miracle, the other now realising that a successful implant didn’t mean happy ever after. Bad news travels fast and a sombre mood soon spread through the hospital. Abel’s nurses and physiotherapists thought they’d lost him after months of intense effort to get him over the brain haemorrhage, which would have been a tragedy for us all.
Fragile Lives Page 9