Archive for September, 2009

Stories From a Heart Surgeon

Before I was ever sucked into the world of Congenital Heart Defects, the following New York Times article would have been vaguely interesting to read but certainly not powerful and touching.  Now, after having been through one open heart surgery to repair Tetralogy of Fallot and expecting another valve replacement surgery in less than a year, this article is emotional and awe inspiring.  I don’t usually share articles in their entirety but I think this article is worth sharing.

“BODY AND MIND; Baby Heart on Hold

By JOHN STONE, M.D.; John Stone is a cardiologist at the Emory University School of Medicine; his latest book of poetry is ”Renaming the Streets.”
Published: Sunday, July 10, 1988

IF WE ARE TO BEGIN AT THE BEGINNING, it must be way back. In the yolk of time. The problem began with the embryo, the cells of which divide, burgeon, twist and unfold, yielding to the wash of DNA and the codes of its helix.

The embryo is an architect; it must invent, out of all that has gone before, the city it plans to inhabit. The work is precise and delicate; a wonder that trouble doesn’t occur more often. Virtually all creatures develop in this way. That is why the premedical student can study the stages of growth of the chick embryo and extrapolate to the human. Thus, every human embryo, passing through the gill-slit stage on its way to lungs, rehearses the moves of the chicken that has crossed this road so many times before, effortlessly, within the chalk walls of the mother shell. It is a magical act, predestination come to pass, a virtuoso performance until, in the case at hand, a little patient I’ll refer to by his last initial, L., somewhere between the third and sixth weeks of pregnancy, when it came inexplicably to grief: a million commandments all obeyed to the letter, except for the one that mattered to this child.

L. is almost 2 years old; he first came to the university clinic because a heart murmur was heard shortly after birth. Though small for his age, he is alert and bright. His condition is called tetralogy of Fallot, the most common cause of the so-called ”blue baby.” Study of his cardiac anatomy with the echocardiograph has been diagnostic for tetralogy. The sonar waves outlined two main and interconnected problems: narrowing and partial obstruction of the artery to the lungs; and a defect, a ”hole,” in the wall, or septum, that divides the right and left ventricles, a ventricular septal defect. Though the French physician Etienne Fallot, in 1888, described four problems (hence, tetralogy), these two basic defects account for L.’s blueness. Dark unoxygenated blood surges through the veins back to the heart from the body (where it has given up its oxygen); entering the right ventricle, this venous blood finds the way to the lungs partially blocked, so it takes the path of less resistance, across the septal defect into the left ventricle. There, the dark, ”blue” blood mixes with the bright red oxygenated blood headed out to the body: that is why his skin is blue, why his growth has been slow. Most alarming today, his blueness is worse.

L., says his mother, has been more listless since his last visit to the clinic three months ago: not eating as well, resting more, playing less. ”And his lips and fingers turn real dark-blue after he plays hard,” she says. I let him sit on his mother’s lap and ease my stethoscope under his shirt. He doesn’t cry; he’s a veteran at this. The loud murmur is unchanged. But his mother is right, as mothers often are: his is bluer today; his nail beds, his lips, are not simply bluish, they’re purple. As he falls quietly to sleep on his mother’s lap, I seize the opportunity to take a quick reading on the oximeter, which gauges, painlessly, the oxygenation of the blood.

The pulse oximeter is a recent technology that uses light sensors to measure the ratio of unoxygenated to oxygenated blood passing through the vessels of the finger or ear. The instrument monitors, continuously, for ”blueness,” or cyanosis. The widest use of oximetry is in the detection of possibly lethal falls in blood oxygen in patients in operating rooms and intensive-care units (where it has prevented hundreds of deaths).

The nurse slips L.’s index finger into the padded chamber; within seconds, there’s a readout of the arterial blood oxygen saturation: 73 percent. I stick my own finger in, the gadget beeps: 94 percent. The obstruction in the artery to his lungs is gradually worsening. He will definitely need surgery – and soon. I explain this to the mother, still holding him, asleep like a dusky statue in her arms. She doesn’t cry, either. She has been expecting this.

More than 25 years ago, I flew from Georgia to the Mayo Clinic in the hold of a huge military transport, one volunteered by the local Air Force base. A nurse, Alice, flew with me as we ferried a cyanotic infant, only a few weeks old, who also had tetralogy of Fallot. The boy was more seriously ill than L. – much smaller, bluer. Alice and I had rigged up, in the vaulted whale’s belly of the plane, a bassinet that swung lightly, like a cradle, from the arching ribs of the hull. The plane was too noisy for much talk, but we could see what was happening. The baby was fine, only slightly blue, as long as he slept. But when he began to cry, his marginal circulation deteriorated; he then got bluer and bluer, until, at times, he actually lost consciousness transiently because of lack of oxygen. Oxygen was being piped into his bassinet, but when he cried, either Alice or I picked him up quickly and shushed him. Twice during our trip, it was necessary to give him a small shot of morphine. The drug worked within a few seconds to calm him and put him gently back to sleep, while his color changed, by slow degrees, from blue back toward pink in a kind of living litmus test. Both Alice and I were grateful when the plane touched down at dusk on the snowy Minnesota runway and we could turn our passenger over to the staff at Mayo. Within 24 hours, the boy had had his surgery, a palliative procedure that would allow him a chance to grow, in the hope of definitive surgery later. When I last saw him, before he moved to a neighboring state, he was 5 years old, pink, sassy and growing.

Until 1944, no surgery for tetralogy was available. Then, at Johns Hopkins, Helen B. Taussig, a pediatrician, and Alfred Blalock, a surgeon, devised an ingenious approach. [This article fails to mention Dr Vivien Thomas’ contribution as well] They decided to ”bypass” the narrowed pulmonary artery, suturing a (dispensable) arm artery to the pulmonary artery just past the obstruction. Drs. Blalock and Taussig were gratified that their patient ”pinked up” immediately. For years, the Blalock-Taussig shunt (or variants) was the only help available for tetralogy; though this surgery, too, was palliative, its results were dramatic, even miraculous, when one considers that, for centuries, parents and physicians had stood helplessly by while ”blue babies” worsened and eventually died. Complete surgical correction of tetralogy required that the heart itself, sacrosanct and inviolate, be opened; this step had to await development of the heart-lung machine.

AS SURGEONS PREPARE TO PLACE L. ON a heart-lung machine now greatly refined from the first models so as to accommodate infants, his heart – the size and color of a large plum – beats within his opened chest.

First, all the blood coming back to his heart through the veins is diverted through tubing to the machine, which oxygenates, removes carbon dioxide, filters, cools or heats, and pumps the blood coming to it. (Heart-lung machines are of several types, but basically they use either a bubble oxygenator or a semipermeable membrane that mimics the functions of the lung. The blood, thus oxygenated, is cooled or heated, as necessary, then pumped back into the aorta and out to the body, simulating the function of the heart.) The pump technician announces, ”We’re on bypass.”

The child is cooled, a step that decreases metabolism and protects the brain, kidneys and other vital organs. As the temperature falls, his heart slows, then, no longer needed, is allowed to stop.

Each member of the surgical team is intent as the surgeons work through the small, brightly-lit operative field. All this technology, art and science, in the service of one small plum – which is now ready to be opened by the surgeon.

L.’s ventricular septal defect is large, the size of a dime. It is closed by a patch made of Dacron, carefully sewn at the margins into the surrounding heart muscle.

The pulmonary artery is opened and widened, using a patch made of the patient’s own pericardium (the tough sac that encloses the heart).

All the while, the drone of the pump is heard, taking in dark blood through one tube and pumping it back, bright red, to his body through another. The heart is now being sewn closed. The little patient has been on bypass just over an hour; we are ready to ”wean” him from the machine.

His temperature is raised – and, spontaneously, his heart begins to beat again.

The strength of the beat increases gradually, taking over more and more of the pumping function. He’s off bypass now, on his own, and flying. The surgeon’s eyes smile, and I know his mouth is smiling, too. The anesthesiologist doesn’t really need to look at the oximeter reading, only at the child’s lips. He looks anyway.

Now, as I see patient in the clinic three weeks later, he’s certainly not listless; he toys with the blood-pressure cuff, tries to invade a nearby garbage can. The midline incision in his breastbone is healing nicely. He seems not to notice it at all, his mother says. He’s eating well, breathing easily. His arterial saturation is the same as mine: 94 percent. With any luck, he should be cured. He should be ready for kindergarten when it comes, able to keep up with the other kids. His mother smiles gently down at her son, three weeks into his second childhood. His lips are still pink. On this afternoon, that is the only thing in this world that matters.

Drawing”

Powerful and moving and beautiful to those of us who have been down the same road.  Gratitude inspiring to mother’s whose babies lives are in the hands of these cardiac heart surgeons and to those like Taussing who pioneered the way for our “blue babies” to become pink.

As an aside….the picture from this post features a movie entitled “Hearts of Hope” that chronicles a behind the scenes look at the pediatric heart surgical team at The Heart Institute for Children.  I haven’t seen the movie but, if you click on the link above, it will take you to the website for it.

September 6, 2009 at 8:32 pm Leave a comment

Art, Music, Therapy!

Have you ever heard of music therapy?  Sounds kind of fishy, right.  However, the field has studies to back it up as well as some scientific claims to soothing the heart and helping stroke patients, CHD patients and other heart problems.  The following excerpts are from an article by Bianca Tora:

“One such patient is an 18 year old girl profiled in the July 1 2009 issue of the Wall Street Journal. At age 9, she had her second heart transplant. Her body was determined to reject the first heart. She went into cardiac arrest six times in 2 hours. She recalled being “awake” when the doctors were frantically trying to revive her.

Fearing that they would pull the plug on her, she tried desperately to tell the people in the hospital room that she was alive.Recuperating at home was no easy matter; she kept having recurring nightmares in which she watched herself suffering cardiac arrest.

Things, however, began to change when she took up the pen. She began writing down her thoughts about being helpless and scared. She turned these details into poems and stories. Eventually, the nightmares disappeared.

Now 18, she has successfully completed high school and is looking forward to nursing school in the fall.She credits her writing for helping her deal with her heart and surgery. It was her creative expression through writing that enabled her to transform something frightening and painful into a positive goal – to make something of her life.

Researchers are taking note of the positive relationship between art therapy and the heart. Some current clinical data on this relationship include the following:

a) Psychosocial factors like depression and stress have been found to be strong risk factors for heart attacks. In fact, these emotional factors are considered as strong as physiological factors like high blood pressure and diabetes.

According to researchers at Washington University School of Medicine in St. Louis, depression increases the risk of heart disease more than genetics or the environment. This means that any intervention that can reduce depression can benefit the heart. Scientists are working to determine how artistic expression can be considered a valid form of clinical intervention to be used along with exercise, diets and medication for reducing heart disease.

b) Researchers at Temple University in Philadelphia have found that music can offer substantial benefit to patients who are stressed and anxious about undergoing treatment for coronary heart disease. Listening to music decreases blood pressure, heart rate and levels of anxiety in heart patients. In fact, music therapy is getting increased recognition as a viable form of treatment for depression and mood.

Take for example, Justin P, a young boy born with a heart defect. At 8 months, he had heart surgery. Since he was five years old, he has been experiencing attention and behavior problems at school. Unable to “settle down” in the classroom, Justin nevertheless responds well to music, especially songs with a strong upbeat tempo.

His parents decided to place him in a music therapy class when he turned six. Now 7, Justin can play the piano; he is more focused in school; he is just starting to read and he is a happier child.
According to his parents, music relaxes him and makes him more open to their suggestions.

Creative expressions in art, writing and music can be very effective therapeutic processes for children with heart disease.”

These therapies are good for patients and soothing.  They encourage healing and recovery as well as rehabilitation.  The Congenital Heart Information Network claims that “Music Therapy can be defined as the clinical use of music by a music therapist, as a therapeutic intervention for persons who have special needs. It does not claim to cure or to prolong life in the medical sense, but rather seeks to develop the potential of the individual and to improve the quality of human life. Music Therapy uses music as the basic tool for dialogue in much the same way that traditional therapies use language. Because music has universal appeal and is a form of nonverbal communication, music therapy can benefit persons who might be less responsive to verbal therapies. Benefits of music therapy treatment may include the development and maintenance of motor skills, reduced pain perception, enhanced self-esteem, improved speech and language skills, and alleviation of anxiety and depression (Wilfrid Laurier University, 1991).”

If you don’t believe any of these medical claims, then just take it from Paul Cardall.  Cardall is an accomplished musician and amazing pianist.  He was also born with tricuspid atresia, a CHD and is currently on the heart transplant list.  He has been awaiting his transplant for just over a year.  His blog, Living For Eden, has a post entitled “Music Therapy and Good Friends”.  The blog entry shares some great video footage of his friends who include Ryan Shupe, Peter Breinholt, Sam Payne, Charlie Jenkins, and Mindy Gledhill, all musicians who visited and shared a night of music and healing.  Cardall tells his readers “Thought I would share with you some brief video from an intimate night of friends and music that I’ll never forget. I am forever indebted to friends. I’ve said many times doctors have the ability and skills to heal your body but friends heal your mind and transport you from your suffering.”  All scientific evidence aside, Cardall claims that music does lighten the load and promote the healing of his broken heart!

September 1, 2009 at 2:41 am Leave a comment


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