Fragile Lives Read online

  Then the bottom line. They’d already made their decision. She should go directly for aortic valve replacement with a biological prosthetic valve, a valve that does not need anticoagulation, which would endanger the pregnancy. This is what Julia wanted. It had been her decision, and she disliked uncertainty. She wasn’t just feisty, but brave too. No one in the meeting disagreed.

  Would I do it? Well, it would have to be quick and she must spend the shortest possible time on the heart–lung machine. While cardiopulmonary bypass is perfectly safe for the mother, it often proves the trigger for foetal death as the uterus and placenta don’t like it one bit. The clear fluid that’s used to fill the bypass machine dilutes the mother’s blood, and this dilutional effect drops the concentration of the pregnancy hormone progesterone, making the uterus less stable and increasing uterine irritability. When uterine contractions appear during cardiopulmonary bypass it’s an important predictor of foetal death. Next, if the foetal heart rate decreases through decreased placental blood supply and low oxygen levels in the baby’s bloodstream, it can trigger a distress response. This raises blood pressure and puts pressure on the developing foetal heart, which often fails to recover.

  I explained how to manage cardiopulmonary bypass in a pregnant woman. We needed to use higher pressure and flow than normal, and avoid cooling so that the placental blood vessels wouldn’t constrict. Rapid surgery was vital. The cardioplegia solution that was needed to protect Julia’s thickened heart muscle contained high levels of potassium and the baby’s heart would be very sensitive to elevated levels of this. Too much maternal cardioplegia could stop it.

  So we had to monitor the foetal heart rate and uterine contractions, and if we detected contractions we could infuse the pregnancy hormone progesterone to dampen them down. We could also increase the heart–lung machine flow if the foetal heart rate dropped. As long as everyone knew precisely what to expect I felt we stood a good chance of keeping the baby alive.

  By now the mood had shifted away from terminating the pregnancy towards keeping the little family together. But we needed back-up. Should the baby die and spontaneously abort during the night the gynaecologists needed to be prepared, as they might have to treat uterine bleeding in a patient who’d just had heart surgery. The departments were in different buildings but at least on the same campus.

  The following day was Friday, not a good day on which to operate, what with locum doctors and agency nurses working the weekend. I needed the best team I could possibly muster, and as Julia was perfectly stable I decided we should do it on Monday morning. No fuss. Just another aortic valve replacement, but with a careful plan and the right back-up.

  What makes a quick surgeon? Not haste or rapid hand movements. In fact, quite the opposite – being well organised, not doing unnecessary things, getting every stitch where it needs to be and not having to repeat anything. So quick surgeons don’t move fast, it’s just a matter of connection between brain and fingertips. You have to be born that way. No amount of training helps with this.

  Now I needed to meet her. Oliver took me to her room on the cardiology ward. She was alone. No family there in the morning. As promised she was feisty and probing, but anxious about what I might say. Nervous that others had repeatedly argued for termination.

  Her first words were, ‘I want to keep the baby.’ I replied that I wanted to keep the baby too. Then we had a working relationship.

  So when would the operation be? I told her it would be on Monday morning, then described the type of valve we’d be inserting and the fact that she wouldn’t need anticoagulation. Clearly this was important for the later stages of pregnancy and delivery. I said that the valve would wear out and that she’d need another one in fifteen years, maybe less. But Julia wasn’t thinking that far ahead. She just wanted this horrific intrusion removed from her ordered life.

  ‘Can I go home for the weekend?’ she asked, eager to make some arrangements and let work know.

  ‘OK, but no riding and no exertion – of any kind! But you’ve got to stay right now until we’ve cross-matched your blood and the anaesthetist has been to see you.’

  Oliver agreed that it was a good idea for her to go home and that there was no point insisting otherwise. Monday’s anaesthetist was Elaine – I called her to explain the delicate situation and she came directly. As Elaine talked to Julia I went to warn the perfusionists and give them some literature, telling them what I wanted and emphasising that two lives were at risk this time.

  When I next saw Julia at 7 am on Monday she was perfectly calm. She asked me to save the deformed valve as it belonged to her and she wanted to keep it. Her whole family were in the room – husband, sister and her elderly parents, all there to lend moral support. I said I’d come back and talk to them later.

  The arterial and venous monitoring cannulas were put in using local anaesthetic. I really didn’t want to monitor the foetal heart rate. I’d done that before and found it a source of anxiety and distraction if the rate slows, given there’s nothing we can do to change things when we’re already taking the appropriate precautions. Elaine was careful to keep the blood pressure and oxygen levels up during anaesthetic induction. We checked the foetal heart rate before taking Julia through into theatre. It was normal – 140 beats per minute, twice that of the mother. The echo probe was pushed down the gullet and into Julia’s stomach, ready to view the heart. We kept her covered with blankets until the last minute, to avoid cooling. Then off with everything. The little abdominal bump was there to remind the team to stay focused.

  Soon she was painted with antiseptic and covered in blue drapes, with just the long, narrow furrow between her breasts left on display under the iodine-impregnated adhesive drape. We attached the electrocautery, defibrillator and pipes for the heart–lung machine to the operating table, and then we were ready to go.

  My scalpel sliced through the skin layer – there was more bleeding than normal because of the hyperdynamic circulation – then the electrocautery cut through the thin layer of fat down to the bone. Now the saw up the middle of the breastbone – buzzz! The bit that turns the students’ stomachs and makes them faint. It oozed marrow. More cautery through the remnant of the thymus gland, then into the pericardium. Elaine gave the heparin in readiness for cardiopulmonary bypass.

  We inserted the cannulas through snares in the aorta and right atrium, then it was on to the machine. We stopped ventilating the lungs and the circuit took over, and instead of cooling we used the heat exchanger to keep her warm and high pump flow to keep both uterus and placenta happy. With a clamp across the aorta, in goes the cardioplegia fluid until the heart stops dead. Not really dead, but flaccid and cold, protected by having its metabolism halted.

  I used a scalpel to slit open the aorta and expose the offending valve. It was not recognisable as a valve. Just as the echo indicated, it was a rock-solid volcano with a narrow slit. I cored it out in one piece with a different, sharp-pointed blade, then placed it gently in a bottle of preserving fluid, my gift to Julia. Next I sewed in the new biological valve with twelve separate stitches. This had been carefully constructed from the pericardium of a cow and was suspended from a plastic frame with a sewing ring. Now it was sewn on to where the old valve had been removed, a common and uncomplicated operation this time benefiting two patients – one present, one future. So far it was going well.

  We sewed up the aorta and removed the clamp, warm blood flooding into her coronary arteries. The heart was reanimated by this life blood, first squirming in ventricular fibrillation followed by sudden spontaneous defibrillation. It lay perfectly still until I poked it, then contracted and ejected blood. After poking it again, normal heart rhythm began, the echo probe showing the artificial valve opening and closing. The way out of the left ventricle was now wide open for the first time in decades and thousands of small air bubbles dashed towards the needle. Routine and unexciting was precisely what we needed.

  I told Elaine to start ventilating the lungs, check
the blood gases and get ready to come off cardiopulmonary bypass. She rhythmically pumped air into the windpipe and the collapsed lungs filled with air and expanded – from flaccid and empty to inflated, pink and proud. They surrounded the heart, same as always, day after day. We stop life and start it again, making things better, taking calculated risks.

  A pulse wave returned to the arterial pressure trace, now regular and strong. But I wasn’t looking at the screen. I was watching the heart itself, still pushing out the last residual air bubbles. They floated upwards, straight into the right coronary artery, now obstructed by coalescent air. The right ventricle lost its blood supply and temporarily distended. No big deal. We increased pump flow and blood pressure to push the air through. The right ventricle contracted again, and all was well.

  Now I wanted to get off the machine as soon as possible. I told the perfusionist to slowly ease off bypass to let Julia’s replumbed heart take over. We’d been on the machine for just forty-nine minutes, and during that time we’d maintained high flow rates and normal temperature, doing our best to look after the uterus and its precious cargo. I heard ‘Off bypass’. We remove the cannulas and reversed the heparin anticoagulant with protamine.

  The cut surfaces were still bleeding, more than usual. My ADHD and irritable bladder kicked in and I felt it was best to let Mohammed finish off – cauterise the bleeding sites, put the drains and pacing wire in, make sure she’s safe. We were trying to avoid blood transfusion with its negative effects, but at the same time we didn’t want oxygen delivery to be compromised by too few red cells. Eventually we needed to give her two units of donor blood, and fresh frozen plasma with its clotting factors, followed by platelets, the sticky cells that plug small holes. Within an hour she was ready to transfer to intensive care, her bleeding under control.

  Elaine and Mohammed escorted Julia out of the operating theatre complex, elated that everything had gone according to plan. Yet after all the preparation they were greeted by an inexperienced nurse. The intensive care unit had been warned like everybody else – and it was hardly the poor nurse’s fault – but Elaine was irritated. What was the plan to look after the baby? When was the most likely time for the baby to die? What would we do if Julia had a torrential bleed down below? Blank faces, wide-eyed nurses, stupefied junior doctors. So get an experienced team together and get focused. I was unaware of all this at the time but Elaine was right. Experience matters a great deal in high-risk situations, and in this case two lives were at risk.

  Julia’s blood pressure was on the low side. Her blood vessels were more dilated than usual because we’d kept her unusually warm on the bypass machine, but we couldn’t give her the standard drugs we used to increase pressure as they’d constrict the blood vessels to the uterus and placenta. Nor could we allow an average blood pressure less than 70 mm Hg. The solution was in the guidelines. Everybody had it, but did anyone in the intensive care unit read it? No point saying anything, otherwise there would be a complaint.

  When I returned I asked Mohammed to stay with her. Oliver used an ultrasound machine to image the foetal heart, which was still beating away at around 140 beats per minute. So far we had a viable foetus and no uterine contractions, so I told them to let her wake up, take her off the breathing machine and get rid of the sedative drugs. Then her blood pressure would rise spontaneously. I left to operate on my next patient with a parting shot – ‘You’re looking after two people now, not just the one you can see.’

  Julia woke up quickly and eventually had the tube removed from her windpipe. She described being awake with the tube in as the worse part of the whole experience. I met Oliver at seven o’clock the following morning to image the foetal heart, still bounding away at 140 beats per minute. Not just that, but the foetus was doing somersaults in the womb. And Julia’s heart was working well with the new valve – she had warm feet and a good volume of urine in the catheter bag. Medicine is the only profession where piss is a cause for celebration. Nonetheless I remained uneasy, as her blood pressure was on the low side. Our incomplete understanding of heart surgery in pregnancy meant that we didn’t know if it mattered at this stage, but we still didn’t want to use drugs that would compromise the placental blood supply.

  On awakening, Julia’s first question was whether her baby was still OK. We reassured her that it seemed to be, but we looked forward to finding a strong heartbeat in another twenty-four hours. By then I felt we’d be in the clear. Later that morning we took the drain out of her chest. She was desperate to get back to a single room on the ward but I wanted her blood pressure and oxygen levels monitored for another twenty-four hours. We moved her to a quiet isolation room normally used for septic patients.

  The next day the foetus was still the same, moving and with a normal heart rate, but Julia was uncomfortable. The second post-operative day is always the worst, the first day bringing the euphoria of survival, the next just pain. Unfortunately, for the baby’s sake, we couldn’t give her a heavy analgesic regime.

  We operated on Monday. By Friday Julia was bored, comfortable and insisting on going home. We couldn’t stop her. A concerned Oliver called her each day for the next week, then saw her regularly in the outpatients department. Foetal ultrasound scans showed normal growth and activity. Five months later, in January 2016, she delivered a healthy baby boy weighing nine pounds – her miracle child, once destined to be a heap of scrapings in a stainless steel dish. We changed all that, Oliver and me. Welcome to the world, Samson. Strong man!

  16

  your life in their hands

  Have a heart that never hardens,

  And a temper that never tires,

  And a touch that never hurts.

  Charles Dickens, Our Mutual Friend

  It was 2004, almost fifty years since that television programme planted the seed in my cerebral cortex – Your Life in Their Hands from the Hammersmith Hospital, the programme that shaped my destiny. The BBC had called my office and spoken with my secretary Dee. She was excited when I popped by in between cases. Would I consider doing a show for them, a full hour of prime-time television? They were looking for a brain surgeon, a transplant surgeon and a heart surgeon. The name of the series, Your Life in Their Hands.

  The distinguished producer and his female assistant came to Oxford to talk through the implications, explaining that the filming could be intrusive for a while. They’d spend six months with me at the hospital and at home, meeting the patients and interacting with my family, so viewers could appreciate how it felt to be a heart surgeon. Life at the sharp end, in my case very sharp.

  They wanted me to implant a Jarvik 2000 for the cameras and asked whether I could find them an appropriate heart failure patient to follow, before, during and after the operation. Of course, they would feature other cases. They’d like a baby case and other dramatic, high-risk stuff – cutting-edge, inspirational surgery in real time, whether the patient lived or died. They’d do the filming and decide what material to use. No pressure, then.

  From their background research they knew that I regularly operated live for surgical audiences, and that I was flamboyant and a confident performer, not easily intimidated. If I agreed to do it they’d make the arrangements with the hospital. At the time we had a chief executive who actually talked to us, a likeable guy who periodically emerged from his ivory tower to visit the worker bees – I was in no doubt that he’d agree to it. Now I just had to let my family know that a film crew would be coming home with me after work. And meeting me in the mornings. And interviewing them. How was it to live with a heart surgeon? Good question!

  It soon became normal to have a film crew on my shoulder. Many operations were recorded: premature babies with holes in the heart, young adults needing massive surgery for Marfans syndrome and a middle-aged lady needing her fifth aortic valve replacement, a difficult procedure that eventually took tweny-four hours. Things went dramatically wrong on camera but she survived. Of course they used that material.

  They filmed m
e jogging with Mark and watching Gemma play golf for Cambridge University. But after several months there was still no suitable candidate for the Jarvik 2000. Eventually I called Philip Poole-Wilson at the Royal Brompton Hospital. It took him less than a week to locate the ideal patient, a delightful fifty-eight-year-old Scotsman who’d already been turned down for transplantation in Glasgow. Jim Braid was very much in the mould of Peter Houghton. He was dying but desperately wanted to survive long enough to see his daughter graduate and get married. As the clock ticked on relentlessly it was clear that he wouldn’t make it.

  A long time had passed since Jim’s transplant assessment and we needed up-to-date information. Philip brought him down from Scotland and admitted him to the Brompton. He needed repeat right and left heart catheterisation, detailed echocardiography and lots of blood tests. I was mindful of the fact that we were still paying for all of this out of charitable funds. The NHS wouldn’t pay – they’d written him off like Peter and the others. I was his only chance.

  Glasgow were correct about him being unsuitable for a heart transplant. The blood pressure in his lungs was too high, although Jim’s own right ventricle was used to it. It was his left ventricle that was going down. He had the same problem as Peter – dilated cardiomyopathy. Nor were his kidneys working well enough to tolerate the immunosuppressive drugs that a heart transplant would need. A left ventricular assist device would take over from his flabby, failing heart. Not only that – it might help to rejuvenate it. Possibly. The echo showed it certainly couldn’t afford to get any worse. It was now or never. We couldn’t risk letting him go home to Scotland.

  I took the excited BBC team down to the Fulham Road to meet Jim and his wife Mary. Peter Houghton came down from Birmingham and was on great form, still raising money so that others could have pumps. It had now been almost four years since his implant and he was approaching the world record for survival with any type of artificial heart. He was pleased to counsel Jim and Mary, doing it professionally and keen to be regarded as part of the team.