Fragile Lives Page 20

  This was too much for Anna, too much for David – and Des – as well. It was easy to understand their standpoint: how much could one person endure, why was God letting this happen and, more to the point, where to go from here? This last question needed careful consideration. How much heart could be removed from this young woman? The situation was too emotionally charged to make a quick decision, so Anna and her dad went home in abject desolation. Dr Forfar had to think about it as well and would discuss it with me, but he let the family settle down for the Christmas period. Of course they couldn’t rest. Peace of mind was impossible, as Anna knew this was a death sentence.

  She returned with David in early February, and Des came too this time. There was no uncertainty for him now, only the discussion about what could be done – if anything. A repeat echocardiogram made them unbelievably miserable. All of Anna’s four myxomas to date had grown rapidly, although they were benign. This new one was 2 cm in diameter and already prolapsing dangerously through the mitral valve, so a further stroke was likely.

  Dr Forfar called me with the dismal news. What did I think? Would Anna be considered for a heart transplant? Sadly not. A transplant leaves a large cuff of left and right atrium to which the donor atria are sewn, so it wouldn’t protect her. A heart and lung transplant could remove the whole heart, but no one would consider that because both lungs were stuck to the chest wall after the previous surgery. I said I was willing to operate again, but we all needed to agree that it would be the last time. Between the two of us we felt that we couldn’t just leave Anna to the inevitable.

  When asked, the family agreed that she’d rather die during the surgery than be abandoned. In the event of success there would be no further echocardiograms. A head-in-the-sand strategy, admittedly, but there was no point in making everyone miserable again.

  Anna was admitted on Valentine’s Day, eleven years to the day after she and Des were engaged to be married. This fifth operation was predictably difficult and dangerous. With patience and great care, we re-entered the chest and dissected out just enough heart to get back into the right atrium. Having achieved that safely I went out for a break. This is a good strategy in complex reoperations and a necessary one for surgeons with an ageing bladder. Now for round two.

  I opened the right atrium to approach the left, intending to go directly through the patch from operation three. At the mouth of the inferior vena cava draining from the abdomen was a completely unsuspected right atrial myxoma, as large as the one we were chasing on the left. We removed it, although in truth it almost fell out. Then we lifted out the left atrial myxoma. Job done again, with a great sense of satisfaction. We closed up the heart, removed the air and warmed the blood. Unperturbed by this fifth insult the much-abused little organ bounded off the bypass machine. Two myxomas for the price of one. Again. We closed the chest over it, never to be exposed again. Relief for me, resignation for the family.

  At first the post-operative course was straightforward. Anna spent two days on the ventilator, then the tube was removed and she had frequent physiotherapy. Everyone was elated that she’d survived. Then she was given some soup without adequate supervision. With the brain stem stroke her swallowing had always been an issue, and she inhaled the hot liquid, then choked. There followed a long period on the ventilator with a chest infection, which needed several courses of antibiotics and eventually a tracheostomy. But she came through in the end and was no worse than before. Anna and Des returned home to get to grips with the uncertainty, to try to banish the depression and have the best life possible.

  Time passed and we didn’t bring her back to the hospital. Rivermead were very supportive and kept an interest in her. Above all she was well supported by the church and the community. From time to time I would ask Dr Forfar whether he’d heard anything, although after a while we both lost track of her and heard nothing until I discovered that a neighbour knew her well from church. Then I had serial updates. She was happy. Des was happy. He’d stuck by Anna through thick and thin. Occasionally I would receive a card.

  In 2015, more than ten years after her fifth and final operation, the Annamobile pulled up outside my home. She was in her wheelchair at the back, beaming and blooming. Des came to the door with a cake. With the carers’ help Anna had made it for me to celebrate their twenty-first wedding anniversary.

  So what had happened to the myxomas? The genetic storm had abated and the battle was won. With divine help I expect. It brought to mind a line from ‘The Flower’ by the seventeenth-century poet George Herbert: ‘Who would have thought my shrivel’d heart could have recovered greenness?’

  I hope they both live happily ever after.

  12

  mr clarke

  Before you tell the truth to a patient, be sure you know the truth and that the patient wants to hear it.

  Richard Clarke Cabot

  18 March 2008. I was ambling back to my office after the first case of the day – a baby with a hole in the heart; nice result, and happy parents – when I saw a woman weeping at the far end of the corridor. She was smartly dressed, with two young children holding on to her coat. Although it was none of my business, after forty years in surgery I was still not immune to other people’s grief. So the desperate little tableau upset me.

  Everyone else strode past them in a purposeful way, going about their hospital duties – nothing to do with humanity or common decency, more about deadlines, figures or waiting lists. I was about to divert towards my office and a pile of paperwork, but I couldn’t do it. Even though I looked and felt a mess in my sweaty theatre gear, I approached her.

  The poor lady was so consumed in grief that she didn’t notice me at all, or if she did she must have thought I was a porter waiting for the lift. Quietly I asked whether there was anything I could do. After a minute passed in which she tried to compose herself, the lady explained that she’d left her husband in the cardiac catheterisation laboratory. He was dying and they’d been told that nothing more could be done. Now she needed someone to look after her children, then she could go back and sit with him so that he didn’t die alone.

  I pressed her for more information. Her husband, Mr Clarke, was forty-eight. Earlier that morning – and without any warning – he’d suffered a massive heart attack. First he was taken by ambulance to the nearest district general hospital, where he suffered a cardiac arrest and was resuscitated and placed on a ventilator. Having established the diagnosis of myocardial infarction, the cardiologist inserted an intra-aortic balloon pump and relayed him on to Oxford – more than an hour away – for urgent angioplasty.

  The objective of angioplasty is to open the blocked coronary artery and stop the oxygen-depleted heart muscle from dying – the infarction bit of myocardial infarction. The cardiologist feeds a balloon catheter through the aorta and into the blocked coronary artery, and it’s inflated to open up the tiny vessel, a small metal stent being inserted to keep it open. In most cases this reinstates blood flow to the compromised heart muscle by a process known as reperfusion. Now the critical bit: reperfusion within forty minutes of the onset of chest pain salvages 60 to 70 per cent of the muscle at risk. Beyond three hours, only 10 per cent will survive.

  Mr Clarke had been bounced from pillar to post, his treatment taking much more time than was reasonable. The treatment guidelines advise the use of ‘clot busting’ drugs in cases of delay. These can dissolve the blood clot that’s blocking the narrowed artery and should restore blood flow – not as good as angioplasty, but better than nothing.

  Oxford has a fantastic emergency angioplasty service. It’s round the clock, all day, all night. Once in the cath lab, Mr Clarke got the best treatment. His blocked artery was opened, but the left ventricle – badly damaged during the delay – now wasn’t moving and there was very poor blood flow. A normal heart pumps five litres of blood per minute, while his heart was managing less than two. With a low blood pressure of around 70 mm Hg, half of what’s normal, lactic acid was accumulating in his blood. He
’d reached the stage we call cardiogenic shock and was sinking fast. Without a miracle he was buggered and his kids would lose their dad.

  I didn’t want that to happen and told Mrs Clarke that I’d see if there was anything I could do to help. Maybe we could try one more thing. Because of our past achievements I’d been sent a new ventricular assist device to test from America. It was time to give it a try!

  We agreed that Mrs Clarke should take the children to the cafeteria to try to divert their minds from the misery and I’d come back to them. I needed to get Mr Clarke into that operating theatre as soon as possible and would have to reschedule the operating plan for the day. We’d start by supporting him on the heart–lung machine to improve his life-threatening metabolic state, then we’d take over from his dying heart.

  I started to make my way down to the cath lab past my Portakabin office. My new secretary Sue was killing ants on the windowsill, still waiting for me to get to grips with my paperwork. Mercifully there was a new excuse for me to avoid it. I asked her to call the anaesthetic room of Theatre 5 and warn them about the change in plan.

  ‘What plan?’

  Sue was quite entitled to ask this, as she’d no idea about Mr Clarke, but there was no time to explain. And could she please warn the perfusionists that I was going to use the new CentriMag pump.

  I wanted to see the coronary angiogram so I knew what we were dealing with and whether the heart stood a chance of recovery. This only took two minutes. The left anterior descending coronary artery had been completely blocked but was now once more wide open with a metal stent through it, preventing it from closing off again. The coronary flow wasn’t as brisk as it should have been, and the echo showed a substantial part of the left ventricle was indeed motionless and not contracting at all, even though the artery was open.

  The $64,000 question was whether the muscle was already dead – myocardial infarction – or whether it was suffering from what we call ‘myocardial stunning’, which, while bad, was not nearly so serious. ‘Stunned’ muscle remains alive but takes days or weeks to recover. We’d find out if I succeeded in keeping him alive.

  There was no chance to explain all this to Mr Clarke, as he was very quickly going downhill. He had the ventilator tube down his throat lying flat on the trolley, and when I tried to introduce myself it was clear his mind was failing, bordering on unconsciousness. His kidneys had stopped producing urine, his lungs were filling with fluid and he was icy cold, deathly pale yet sweating. There was froth in the corner of his mouth, bubbling through blue lips, and his eyes were rolling. This is how heart attack patients die, and was how I lost my grandfather. There was no time to send for porters so I asked the nurses to head for the lifts. Just get him up there before he arrested. I’d deal with the consent form later – whether he lived or died, he certainly wouldn’t be suing me.

  They say everything in life is about timing. In Mr Clarke’s case, timing was the stuff of fantasy – you couldn’t make it up. My chance encounter with the distressed lady on the corridor. An empty operating theatre. And the new CentriMag pump. It was reminiscent of Julie’s good fortune with the AB-180. They were the lucky ones.

  The pump was called a CentriMag for a good reason. The blood propulsion mechanism – known as the impeller – spins within a magnetic field like a centrifuge at up to 5,000 revolutions per minute. Centri – centrifugal, Mag – magnetically levitated. It can pump up to ten litres of blood per minute, far more than needed. Limited pumping capability had been the drawback with artificial hearts from the outset, but now the technology was improving rapidly.

  Mr Clarke, by now a metabolic wreck, was too sick to linger in the anaesthetic room, so he was wheeled directly through to the operating table. To give him a general anaesthetic at that point risked immediate cardiac arrest – instead, the monitoring lines and transfusion cannulas were inserted under local anaesthetic. To keep him alive I had to get him onto the heart–lung machine rapidly, then his blood needed filtering before we switched to the CentriMag system.

  The sternotomy incision was bloodless. Corpses don’t bleed. The injured heart quivered, giving up the ghost, but as always cardiopulmonary bypass changed everything. The struggling heart emptied and I had a good view of the stiff muscle that had been starved of blood and oxygen. It was clear that it wasn’t dead, and I could even see and feel the coronary stent sitting within the artery like a rat in a snake’s gullet, blood coursing through it to the swollen muscle. The ventricle was down but not out.

  Mr Clarke was experiencing a bog-standard death from heart attack, the sort that happens to hundreds of patients every day across the NHS. I had a grim determination to show that he could still be saved with the right technology. For the sake of that family.

  With the CentriMag system, plastic tubing diverts blood from the left atrium out of the body to an external rotating pump head, then more tubing brings blood back to the chest and into the aorta, where it emerges from the heart. A control console the size of an old-fashioned typewriter regulates the pump speed. This simple arrangement bypassed Mr Clarke’s struggling left ventricle and allowed it to rest, at the same time providing generous blood flow to his brain and body.

  By releasing clamps on the tubing we allowed it to fill with blood, which pushed out air. As always the whole system must be airless. It was our obsession – that little saying, ‘Air in the head, dead on the bed’, couldn’t be repeated often enough. Now it was time to switch on the CentriMag. We balanced the reduction of flow in the cardiopulmonary bypass circuit with an increase in the machine’s system, and then it took over altogether, just like clockwork, in a smooth and effortless transition. Magic.

  I looked at the clock. It had been almost three hours since I’d dispatched the grief-stricken family to the cafeteria. Shit. They’d now be sitting there wondering whether he was alive, most probably expecting him to be dead. I felt concerned for them but there was nothing I could do about that now. Good news would make up for it.

  For once I got on and closed the chest myself, taking care to protect the life-preserving tubes. By the end there were two pacemaker wires and four plastic tubes emerging from beneath his ribs, two of which were just drainage tubes to let out blood.

  I went to find Mrs Clarke. By now other family members had arrived to take the children away from the hospital, and I wanted to bring her to the bedside myself. When we both returned it must have felt a bit like being in a spaceship for her – wall-to-wall technology, the ventilator to breathe for him and his circulation supported by the CentriMag. What little space remained around the bed was taken up by monitoring equipment and drainage bottles. Amid all this was her husband’s broken body, something to look at rather than communicate with.

  Her first reaction was alarm – the sight, after all, was an emotional stab wound – and I thought her legs would give way. We moved quickly to sit her down by her husband. Her immediate instinct was to hold his hand. He didn’t respond, but at least he was warm and even pink now, not cold and clammy like when she last saw him, with that greyish blue colour of those dying from cardiogenic shock. The nurses were kind. They scraped Mrs Clarke from the ceiling, then started to explain all the paraphernalia to her. They were confident enough to manage the equipment and the instructions to them had been simple: don’t change anything. We were winning.

  After a week Mr Clarke’s uninjured muscle looked much better, so I decided to take the optimistic route and remove the CentriMag. We returned to the operating theatre, where we slowly reduced the pump flow and watched his heart’s performance on echo. The left ventricle was ejecting well, he had a normal heart rate and adequate blood pressure. There seemed to be little residual damage from last week’s catastrophe. Bloody brilliant, I thought.

  We took out the pump, washed his chest out, put in clean drains and closed him up for the last time. He remained perfectly stable. After another twenty-four hours he woke up and had the breathing tube taken out. He’d returned from his week away as if resurrected
from the dead. When I finally spoke to him he recalled nothing of the events, and hadn’t had any ‘out of body’ experiences or flashbacks. Nor did he have any idea who I was or any recollection of which hospital he was in.

  I wanted to be there when his kids came back – not actually with them, but away in the corner of the room somewhere, just watching as they came in to see their dad. It was certainly worth the wait. Amazingly, just a week after all this, Mr Clarke went home. Equally remarkable was the fact that at his follow-up three months later his heart looked normal. All the ‘stunned’ and struggling heart muscle had recovered. It was a textbook ‘just in time’ job.

  For me the Clarke case was a watershed moment. So many patients continued to die after a heart attack, even when emergency angioplasty had succeeded in opening the blocked vessel. We’d shown that at least some of these victims could be saved with simple, inexpensive technology. It had by now become a repetitive theme.

  Splint a broken bone and it will heal. Rest an injured heart and, although it may recover, it won’t always. But for me the patients deserved that chance. What’s more, the nurses on the intensive care unit found the CentriMag system very easy to manage. Turn it up or turn it down. We had control over the patient’s whole circulation by simply twiddling a knob. It was much more straightforward than driving a car.

  Now the sting in the tail. Six months after Mr Clarke suffered his heart attack the same thing happened to his younger brother, who was just forty-six. I was away at a conference. The second Mr Clarke was taken to his local hospital only to be passed on to Oxford. By that time he was already in cardiogenic shock. His family received the same message as his brother’s family: that there was nothing more we can do. They searched out my office, desperate for help, but I was away, so there was none. No surgeon, no pump. His wife lost her husband, his children their father.