The Heart Healers (10 page)

Well, yes and no. Hypothermic heart surgery proved that a surgeon could operate inside the heart. Yet it was a rocket forever locked on its launching pad, a success in theory but not in practice. Hypothermia was hopelessly inadequate for most cardiac problems. Almost all the other cardiac defects simply could not possibly be repaired in less than ten minutes. And so it is an irony of history that it was not Bigelow, who proved the feasibility of hypothermia, nor Lewis, who performed the first open heart surgery, who would ultimately lay claim to being the Father of Open Heart Surgery. It was Lewis’s thirty-four-year-old assistant, C. Walton Lillehei, who took the giant step that brought open heart surgery to practical reality.

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WITH BLUE EYES
and a square face topped with blond hair resembling an early version of Robert Redford, Walt Lillehei was just beginning his cardiac surgery career.

In 1951 he had visited the East Coast to watch the new breed of “closed heart” surgeons in action. About a decade younger than Harken and Bailey, Lillehei visited Boston, Philadelphia, and Baltimore’s Johns Hopkins, returning to Minnesota inspired to make his mark by operating inside the heart.

Walt Lillehei was the eldest boy in his family. His grandfather was an immigrant Norwegian fisherman and his father became a successful dentist in the Minneapolis suburb of Edina. Young Walt emerged as a gifted child early in his life. Walt’s particular intelligence lay in his aptitude, fascination, and passion for understanding how things worked. He was a problem solver that loved a challenge. In his superb Lillehei biography, author Warren Miller relates that when, as a teenager, Walt was denied the money to buy a motorcycle, he bought the parts and constructed his own. Walt’s creative imagination was clear to his teachers; he skipped two grades, and entered the University of Minnesota at the age of sixteen.

During World War II, Lillehei rose to lieutenant colonel in charge of a Mobile Army Surgical Hospital (MASH) in North Africa where Allied forces battled those of the legendary Nazi Field Marshal Erwin Rommel. At war’s end he returned with a Bronze Star to enter surgical training with the University of Minnesota’s legendary Dr. Owen Wangensteen.

Inside the hospital Dr. Lillehei was a highly respected surgeon, viewed by his nurses as unusually compassionate, and by surgical colleagues as an innovative genius. But outside the starched hierarchy of the hospital, Walt played by no one’s rules but his own. Whereas Charles Bailey scuffled with society’s norms, Lillehei simply ignored them. Walt shared a second trait with many of the innovators we will meet later. He was an unmitigated risk-taker. Walt lived life at double speed. Lillehei’s days were consumed with thoracic surgery, but his nights were gold chains, a Buick Roadmaster convertible, and late-evening carousing. Early on he discovered that the classic good looks of his Scandinavian heritage, gregarious attitude, personal magnetism, and sensitivity held an irresistible allure for nurses, and throughout his career he was not one to ignore it. “Work hard, play hard,” he urged his friends.

If Walt was hedonistic, he had a compelling reason. In his last year of surgical training, Walt noted a small lump in his neck. The biopsy result was chilling. Lillehei had a deadly cancer: lymphosarcoma of the parotid (salivary) gland, with a predicted five-year survival rate of 5 to 10%. After years of college, medical school, internship, and residency training (mine consumed fifteen years, surgeons need even more time), Walt Lillehei had been dealt life’s cruelest blow, a sentence of premature death. On the last day of his surgical residency training, instead of celebrating, Lillehei lay down on an operating table. His boss Owen Wangensteen slashed away all the lymph nodes on the affected side of his neck. Wangensteen was operating in the now largely abandoned era of radical cancer surgery, so he plunged into Walt’s chest cavity to cut away more tissue. At the end of the surgery the pathologist’s microscope shined an oculus on just a tiny sliver of hope: the cancer appeared only on the nodes in his neck. Surgery complete, Lillehei now underwent a course of radiation therapy. His life was dependent on radiation therapy, but his ambition was set free. Told he probably would not survive five years, any stricture on Walt Lillehei’s mandate to “work hard, play hard” evaporated. He could hardly have foreseen that his single-minded pursuit of that motto would lead to a career unmatched for its peaks and valleys among all whom I have known in cardiovascular medicine.

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IN MEDICINE, WE
learn more from our mistakes than from our successes. Error exposes truth. Since we must err, it seems best that our mistakes come first. Bill Mustard’s failed monkey lungs taught a critical lesson: it was possible to oxygenate blood outside a patient’s body, return it to the recipient circulation, and keep a patient alive while operating on an arrested heart. Knowing that, Lillehei’s group made one of those spectacular intuitive leaps of genius that seem obvious in retrospect. Mother Nature offered a better oxygenating system than monkey lungs. When a baby is in a woman’s uterus, it cannot breathe, and so it gets its oxygenated blood from the mother. The ingenious method of blood exchange is through the placenta. The placenta is a highly vascular structure that attaches to the inner surface of the mother’s uterus. A cord of veins and arteries runs from the placenta to the baby’s belly. The placenta collects deoxygenated blood from the baby’s organs, sends it to be reoxygenated in the mother’s lungs, then returns the oxygenated blood to the fetus. The mother “cross-circulates” her blood with the fetus when it is in her uterus.

Lillehei had an intuition. What worked inside the uterus might work outside the uterus. Instead of inserting just a lung into the circulation as Mustard had done, why not insert a whole body? Why not connect up the child with a congenital heart defect to his mother or father’s arteries and veins? The child’s blood could circulate through the parent’s lungs, while the surgeon operated on the child’s arrested heart. The beauty of this approach was that it eliminated the need for a complex oxygenation strategy, since oxygenated blood would be in constant supply to the child from the parent’s normal circulation. If it worked, the procedure would be the essence of simplicity. Only a pump and tubing would be required. Had they come up with the perfect method of oxygenating their patient’s blood, by simply mixing it with a compatible living donor?

Lillehei’s group bought beer keg tubing and a $500 roller pump that could compress the tubing without being in contact with the blood. This devastatingly simple apparatus also eliminated the cleaning issue that was bedeviling those trying to develop heart-lung machines. Just throw away the tubing at the end of the surgery; use new tubing at the next surgery. In dogs, they discovered that both the recipient dog with an arrested heart and the donor dog awoke quickly and appeared normal after a half hour of cross-circulation. They took another step. They created an artificial ventricular septal defect (VSD) in dogs. A VSD is an abnormal hole between the left and right ventricles, which are normally completely separated by a solid muscular wall. Early anatomists wonderfully dubbed this wall a septum, a derivation of the Latin word
saeptum,
which means a fence. A hole in the fence allows the more powerful left ventricle to pump blood into the right ventricle. As with ASD, the added blood floods the lungs. Most children with VSD do not survive to mature adulthood, unless the VSD is very small.

On his operating table, Lillehei set up cross-circulation between a normal dog and one with his artificial VSD; veins to veins; arteries to arteries. During cardiac arrest on cross-circulation, Lillehei found that he could consistently close the canine VSD with sutures in less than twenty minutes. Walt Lillehei was ready to operate on a child.

The newspapers of March 1954 were dominated by a historic moment in science, the explosion on the Marshall Islands’ Bikini Atoll of the fifteen-megaton hydrogen bomb, a thousand times more powerful than the bombs that had leveled Hiroshima and Nagasaki. From my perspective an arguably more important, but less ballyhooed historic event occurred a few weeks later when Walt Lillehei scheduled open heart surgery using cross-circulation at the University of Minnesota Hospital. The donor circulation would be the child’s parent, providing their blood type was compatible. It was just a year and a half after Lewis and Lillehei’s historic beating heart hypothermic surgery had established the feasibility of open heart surgery.

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THE SCHEDULED SURGERY
became the University Hospital’s own megaton bomb. Walt Lillehei was ready but the University of Minnesota was not. Lillehei possessed Charles Bailey’s indifference to criticism, Harken’s charm, and both men’s supreme self-confidence, but it was not enough. When word leaked out about Lillehei’s planned human experiment, as with Bailey at Hahnemann, it precipitated a fierce morality play. The drama pitted the university’s two most powerful physicians: Dr. Cecil Watson, chairman of the department of medicine, and Dr. Owen Wangensteen, chief of surgery, against one another. Watson, boiling with righteous moral outrage, felt Lillehei’s proposal was an abomination. Given the complete uncertainty about the outcome, Watson imagined that for the first time in the history of medicine Walt Lillehei had come up with an operation with the potential to kill two people at one sitting … “a 200% mortality rate!” Operating on a terribly sick child is conceivably justified, he argued, but risking the life of a second healthy person is ethically unacceptable. Once again, Hippocrates made his appearance. Lillehei wanted to stand the oath on its head. Primum non nocere. First do no harm. Lillehei must be stopped.

Lillehei’s mentor Owen Wangensteen was Watson’s equal in power and prestige, and his argument also was based on uncompromising logic. His department of surgery was world famous for advancing surgery through innovation. His star protégé Lillehei had performed the proposed procedure successfully in animals. If Lillehei was denied, blood would stain Watson’s hands … a child would die for no other reason than Watson was afraid to try something new. Watson’s reaction was his own version of the Bikini Atoll. He felt like the top of his head would blow off with the suggestion that he would be painted as a child killer. He was not the real potential killer of innocents, he raged, pointing a trembling metaphorical finger: it was that man, the one who proposed the research, C. Walton Lillehei.

Here then is the classic, explosive confrontation that has bedeviled groundbreaking research through all my years in cardiology. Just eighteen months earlier Lewis and Lillehei’s hypothermic surgery had established the feasibility of open heart surgery. Now where Watson saw risk, Lillehei and Wangensteen saw opportunity. Where Watson saw that both patients might die, Lillehei saw that a child condemned to early death might be given life. The issue as Watson fought Wangensteen on that Minneapolis afternoon was specific to one family, but I see variations on this theme argued in every Institutional Review Board (IRB) meeting, in which we critically review and approve every research project in the medical center prior to its initiation. What criteria are we as a society to use in making such decisions?

My experience provides a bizarre answer. With our human gift of twisted logic, we decide the ethically correct position after we learn the outcome of the research. Charles Bailey was terribly, morally, Hippocratically wrong. Until he was right.

Wangensteen won the argument based on uncertainty: the first-ever human cross-circulation surgery deserved to be tried, because no one could say cross-circulation wouldn’t work, and if the Lord was willing and it worked, this form of open heart surgery could save countless numbers of dying children. The gain justified the risk. Wangensteen and Lillehei prevailed, but Watson made it clear that crazy Walt Lillehei was on a very short leash. The winner of the ethical battle would await the result of surgery. Lillehei’s first patient, two-year-old Gregory Gittens, seemed to do quite well until the second postoperative week, when he developed pneumonia and died. Rather than resolve the issue, the Gittens experience escalated tension to new levels as both sides saw it proved how right they had been.

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AT AGE FOUR
Annie Brown was already clearly destined for a very short life. She had a hole in the wall that separated her right and left ventricles, called a ventricular septal defect (VSD). Annie’s VSD was large, and her lungs were drowning in her own blood. She could not play with other kids because of progressive fatigue and shortness of breath. She had already undergone repeated hospitalizations for pneumonia. Now she had episodes of coughing up blood as the distended blood vessels in her lungs ruptured. Doctors told her parents Doris and Joseph that she would probably not survive to be a teenager.

Imagine the wrenching decision that now confronted Doris and Joseph. They knew that a young Minneapolis heart surgeon named Walton Lillehei had developed a new way of operating on the heart, called open heart surgery, and that he had tested it successfully—in dogs. But they also knew that his first patient Gregory Gittens, a youngster with the same heart defect as Annie’s, had died in the hospital after Lillehei’s surgery. Having lived with Annie’s progressive deterioration, the Browns had little doubt that Annie had a lethal disease. On the other hand, wasn’t the most critical fact that Lillehei’s first case lay prematurely in his grave? How does one balance the remote likelihood of cure against the much more real prospect of immediate demise? The Browns, visualizing Annie’s future without surgery as recurrent hospitalizations punctuating an accelerating, soul-wrenching, unstoppable march toward death, made a choice. They would gamble Annie’s life, and one of theirs, on the young surgeon. Annie would have open heart surgery.

Unaware of this supercharged medical environment, Doris and Joseph Brown gave their consent for Lillehei to operate on little four-year-old Annie. In the university hematology lab, however, they ran into a new wall. Doris’s blood type did not match Annie’s. The mother could not save her child. But what about Joseph? His blood matched. But he was anemic. The blood bank director decreed that Joseph’s hemoglobin level was too low to permit the procedure. Lillehei now flashed the Charles Bailey side of his temperament. He played life by his own rules. He knew more about Annie and Joseph than the hematologist, so the man’s opinion was irrelevant. He bulldozed ahead. But now providence intervened. Annie was again hospitalized with pneumonia, requiring postponement of surgery. Was Annie’s little body sending headstrong Lillehei a second warning?