the surgeon opened the pericardium and placed my hand on the heart.
He yelled, “Squeeze!” and I performed direct cardiac compressions until
someone on the surgical team detected a carotid pulse. I continued
squeezing the heart in my hand until the venous and arterial access
lines for the heart-lung machine were completed. “Squeeze harder, Dr.
D; squeeze harder.” Holding a human heart in my hand and being
told to “squeeze harder” was not something I would have imagined
while in training a few years earlier.
Finally, the patient’s circulation was completely controlled by the
heart-lung machine and I walked out of the operating room, completely
physically and emotionally drained. Making a quick stop to change my
scrubs, which were completely soaked with iodine, blood and sweat, I
spent the next several hours performing other cases, making rounds
and seeing consults. Simultaneously, I thought, “Will the patient live?”
Three hours later, which seemed like 12 hours to me, I made my
second trip to the OR. Dr. G said, “Dr. D, we have tried three times to
wean the patient off of the heart-lung machine and he won’t come off
the pump. It is time to stop the case.” I responded, “Please Dr. G, give
him one more chance.” I had taken care of the patient for four years
and I considered the patient and his family more as friends than as
a patient’s family. “One more time, then we will have to quit,” noted
Dr. G. I slumped over a stool in the back of the operating room while
the minutes ticked by slowly until the time arrived to see what would
happen. Dr. G. instructed his team to slowly wean the patient off of
the heart-lung machine and the patient’s heart took over on its own.
“Thank you, thank you, thank you,” I told Dr. G and his team. The
patient walked out of the hospital almost four weeks later and he lived
for another decade before succumbing to his heart disease.
The acute closure rate for PTCA in those early days was five to
seven percent. Most PTCA procedures were performed in the proximal portion of a coronary artery because of the difficulty navigating
the original rigid devices to the distal portion of a small coronary
artery. Thus, when the artery collapsed during the procedure the
effect on the heart was usually major and many times catastrophic.
The best-case scenario occurred when the patient experienced severe
chest pain and extensive ST elevation on his or her EKG, but would
arrive in the OR conscious on no blood pressure support medication
and would promptly undergo surgery. However, those times when
the heart went into ventricular fibrillation while the patient was still
in the catheterization laboratory and repeated heart shocks were
unsuccessful, the dramatic scenario I just described would prevail.
Amazingly, thanks to the rapid response by the cardiovascular surgeon and his tremendous team, more than 95 percent of emergency
open-heart surgery patients lived and went home in 10 to 14 days.
the availability of “over the wire” balloon technology in the mid1980s and perfusion balloons in the mid-to-late 1980s, when both
developments led to fewer patients experiencing an unsuccessful
interventional procedure. Finally, once stents were introduced in
the 1990s, the number of cases rushed to the OR shrank drastically
and became almost non-existent. While those developments were
both life-saving for the patient and resulted in a much less stressful
procedure for the cardiologists, those of us who performed the early
fixed-wire PTCA cases will never forget the apprehension when we
pulled a small balloon with a tiny fixed wire back across the blockage
and waited to see if the artery remained patent. If the artery started
to close, there was a good chance the balloon might not cross back
through the blockage and an even greater chance the artery would
not stay open even if the lesion could be re-crossed.
Twenty to 30 years later, I was always pleasantly surprised when
patients would stop me in a shopping mall or on the street and say,
“Doc, do you remember me? Back in the early 1980s you ‘saved my
life!'” The good news was greater than nine out of 10 times, patients
were thankful because they had a successful balloon angioplasty
procedure instead of going through single or double open heart
by-pass surgery. Even in those early days seven out of ten times
most patients did not need a repeat balloon procedure. If the patient
who thanked me for “saving” his or her life had undergone emergency surgery, I always remembered their dramatic course from
unsuccessful angioplasty to the operating room. For patients and
interventional cardiologists today, the seemingly high unsuccessful
rates from the early 1980s seem dismal; however, in the early 1980s,
those statistics were very encouraging because of the number of
patients who avoided undergoing open-heart surgery.
Back at the hospital the next morning, I went to see the patient
who was now awake and off of all blood pressure support. I started
to breathe more easily because I felt reassured the patient was going
to live. Once extubated, he was able to communicate with his family.
The patient was glad to be alive and remembered nothing, a blessing
in disguise. For our team: another day; another procedure; another
angioplasty to perform.
David Dageforde, MD, is a retired interventional cardiologist and now
serves as Board Chair for the Shawnee Christian Healthcare Center.
Knowing the potential for catastrophic outcomes in the early era of
unsuccessful angioplasty, I initially would go to the operating room
repeatedly to see how the surgical case was proceeding. I eventually
learned my emotions were best handled if I waited until the case
was over to hear the outcome. Rushing to the operating room after
an unsuccessful angioplasty procedure seemed too frequent until
JANUARY 2016
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