The Heart Healers (11 page)

When she recovered from pneumonia, Lillehei did not hesitate. The hubris of Lillehei’s approach, the intensity of Watson’s opposition, and the life-and-death stakes for both little Annie and her father created a crackling electric tension as little Annie and her father, Joseph, were wheeled into the crushingly small white-tiled, green-walled Operating Room II of the University of Minnesota Hospital. Two sets of surgeons awaited, huddled back-to-back over the two operating tables, shoehorned between two anesthesia teams and a bevy of OR nurses. Lillehei was assisted by Dr. Richard Varco, a surgeon many years his senior.

Now captain of the ship, Lillehei recognized he needed more than a perfect surgical procedure. He could lose his patient because of inattention to any number of details. No one knew anything about anesthesia under these conditions. The father, Joseph, had to be asleep, because any movement could lead to catastrophic dislodgement of the complex tubing connections. But little Annie was about a fifth the size of her father. They would be sharing the same blood. Would the anesthetic dose necessary to put Joseph to sleep be fatal for Annie? The father and child had markedly different cardiac output. So the amount of blood entering and leaving Annie’s body had to be precisely controlled. If little Annie received either too much or too little blood, her brain might be either starved of oxygen or engorged with blood. The tubing connecting the two patients had to be handled with utmost care. Accidental entry of a small amount of air could obstruct vessels in the brain or heart, causing a stroke or a fatal heart attack.

Two teams of surgeons, packed sardine-close, self-schooled from the same procedure in dogs, connected the maze of tubing. Tubes in Annie’s two major veins that return blood to the heart were connected to Joseph’s leg vein, which would send Annie’s blood on to Joseph’s lungs for oxygenation. A second set of tubes delivered the oxygenated blood from Joseph’s leg artery back into Annie’s aorta.

Lillehei announced he was ready. He turned on the pump and tightened the tourniquets on Annie’s two veins. Now Annie’s heart and lungs received no blood. Annie was “on bypass.” With the pump on and blood from the two souls intermixed, for the first time in biologic history, a child’s life-giving blood supply would be dependent on cross-circulation from the father instead of the mother.

Lillehei cut into Annie’s right ventricle. He adjusted a headlamp, borrowed from an otolaryngologist (an ear, nose, and throat specialist), to improve his visibility. Its beam was far narrower than those we use in today’s cardiac surgery. Magnification, a huge boon to suture placement, would also come later. With the pump on, Lillehei grasped his scalpel, then cut into Annie’s heart to expose the ventricular septum. He saw it immediately The gaping hole in the tiny heart appeared to be about the width of two of his gloved fingers. As Varco pulled apart the incision in the right ventricular wall to widen his field of view, Lillehei began placing sutures with consummate hand speed, while observers strained to see from balcony seats.

In training, I found these seats hopeless. Even if you manage to peer through the constantly fluctuating cracks between the surgeons’ shoulders, the head surgeon is tying his knots deep within a small hole. As a medical student I spent hours practicing being Lillehei putting thousands of “two hand” and “one hand” surgical knots on bedposts and railings. At the operating table I later learned that although it’s easy enough to tie a knot, it is an order of magnitude more difficult to learn to deliver that knot precisely into a deep hole.

Lillehei’s hands flashed in constant motion as he deftly placed a knot, then pulled the two ends of the suture material together for Varco’s scissors to sever the ends of the thread. Knot, cut. Knot, cut became a silent ballet as they delivered seven sutures in the span of ten minutes. The hole between the ventricles looked like it was completely closed. Lillehei nodded at Varco. They had eliminated the cause of Annie’s heart trouble. Vindication, it seemed, would belong to Walt Lillehei.

But as Lillehei began to close his right ventricular incision, disaster struck. Annie’s heart rate fell to about thirty beats per minute, half its normal rate. The normally coordinated beating of the atria and ventricles became completely disjointed. The eyes of every surgeon on both teams immediately focused on Annie’s ECG, but every doctor already knew. Heart block!

What is heart block? Some tiny blocks in the heart’s electrical system are like a grain of sand dropped into a Rolex. In its most severe form, called complete heart block, the electrical impulse activates the atrium but stops there … it never reaches the ventricles. When this happens the ventricles have to rely on their own backup generator. But this backup system delivers only about twenty to thirty electrical stimuli per minute, instead of the normal 60 to 100 impulses. The very slow ventricular contraction rate results in insufficient blood flow to the brain, with the likelihood of sudden fainting, seizures, and the ever-present risk of sudden death. In the days before the invention of the pacemaker, complete heart block was a metaphorical Sword of Damocles, a death sentence without a specific execution date.

Lillehei wondered if his last suture had inadvertently compressed her heart’s electrical conduits, which pass within millimeters of the VSD. Should he remove that last suture and settle for incomplete closure of the hole, or should he hope that the block would only be fleeting? Uncertainty reared its ugly head. Pacemakers were still in the future. Lillehei had no effective treatment for heart block, as he stood transfixed by the world’s first heart block induced by VSD closure. There was no good answer. They had been on cross-circulation for eleven minutes. Lillehei and his surgical teams decided to hope. No doubt some prayed. The room turned deathly still as they stood and watched. With each ticking second, however, hope slipped further through their gloved fingers.

Then at ninety seconds came the miracle. As suddenly as it appeared, the heart block disappeared. Annie’s heartbeat more rapidly and coordination returned to the chambers of the heart. At thirteen and a half minutes, Lillehei decreed that the moment of truth had arrived. “Release the tourniquets,” he ordered. Lillehei stared down at her heart as the pump was turned off. Annie’s heart, now filling with blood, contracted vigorously, a Little Engine That Could. Lillehei placed his hand on the tiny heart. No vibration. His sutures had completely closed the VSD. He and Varco’s eyes locked above their white cotton masks and they reached bloody gloves across the table to shake hands. Survival was now up to the rest of Annie’s body. If Annie could just recover to grasp more tightly the good fortune that had escaped his first patient Gregory Gittens’s tiny fingers, she would have been granted a lifetime in less than fifteen minutes.

As Joseph regained consciousness, he asked about Annie. Lillehei replied that he had found exactly what they expected. He had closed the defect completely. Annie’s heart beat vigorously before he closed the chest wall. He was very, very pleased with the result. Joseph’s thrilled response to his words proved that Walt Lillehei had finessed Cecil Watson’s trump card, the unknown risk to the parent. He had proven that his idea was feasible. But the jury was still out, and he could feel Watson’s furious eyes boring into his back.

*   *   *

ONE WEEK LATER
Walt Lillehei held a press conference, a distinctly questionable behavior for a physician in an era of strict rules of professional propriety that prohibited physicians from advertising themselves to the public. The appropriate professional way to announce a scientific advance was to do as Bailey had done with his mitral valve surgery, at a major scientific conference of your peers, who would debate and dissect the strengths and weaknesses of the new method. Walt Lillehei chose the path less traveled. At his press conference, he recounted Annie’s and her parents’ medical travails prior to surgery. Then came the illustrations. A sensational photograph taken in the operating room on the day of her surgery. Diagrams explaining his method of cross-circulation. Drawings of the heart with a VSD. And then his pitch: “We have long felt that there must be some simple way of working inside the heart. When elaborate machines designed as a substitute for the heart and lungs proved unsatisfactory we tried using the animal’s own lungs and substituted the simple mechanical pump for his heart.” Next came a four-page handout in case you missed (or failed to grasp) important details for your stories. The slides, photo, and the handout—a masterpiece of medical advertising—were certainly more than enough for any press conference, but not quite enough for Walt Lillehei.

A door to the auditorium was flung open, and there was Annie Brown, preternaturally pretty with dark shoulder-length hair and bangs neatly framing a round face with irresistible big brown eyes. Sitting in a wheelchair pushed by her parents, Annie seemed the picture of health with rosy cheeks and a tiny shy smile. In that profoundly emotional moment, pens and typewriter keys hung in suspended animation. Joseph and Doris then recounted the details of Annie’s desperate early years and with glistening eyes spoke of her last days of precarious hold on life prior to surgery. It seemed almost impossible to reconcile her parents’ image of that dying child with the one they looked upon now. By the end of the conference, few dry eyes remained in the auditorium. Lillehei had convinced the reporters that they were looking upon a modern miracle, the story of a lifetime, and they intended to report it just that way.

Annie posed for pictures with Lillehei and her parents. In an era when racial tension in the South and confrontation with communism abroad dominated the news, irresistible little Annie’s story went viral.
The New York Times
offered the headline: “Impossible Surgery Now Done,” while London’s
Daily Mirror
gushed that Lillehei’s surgery was as “fantastic as any ever written in a shilling science thriller.” Walt Lillehei’s theatrics had shocked the world, and inevitably torched more bridges with his medical brethren. With some of his conservative surgical colleagues, this time he had crossed the Rubicon. At that moment, however, he hardly needed their support. C. Walton Lillehei ruled the domain of cardiac surgery. As with Caesar, however, he would one day face daggers.

Always photogenic, Annie Brown became Minnesota’s most recognizable child. Senator Hubert Humphrey sent her birthday cards.
Cosmopolitan
magazine ran a six-page photo article on Annie and her family. She was chosen Queen of Hearts for the state of Minnesota, and for the American Heart Association.

By the time of his press conference, Lillehei had a second surgical success. Engulfed in the clamor for interviews and a torrent of calls from desperate parents with sick children, reckless Walt Lillehei quietly revealed the other side of his complex personality, the side that endeared him to the friends who would stand by him during future days when the world forsook him. Just four days after the press conference, sensitive and compassionate doctor Walt, so well-known to his patients and nurses, wrote a letter to Gregory Gittens’s parents.

It is still a source of bitter disappointment to me that we were not able to bring Gregory through the postoperative period after the operation had seemingly gone so well. I do wish to tell you again that had it not been for the encouragement gained from Gregory’s operation, we would not have had the courage to go ahead with these other children. I feel greatly indebted to both of you.

Frances Gittens’s reply captures the heartbreak and hope of an era when heart disease was still untreatable. “Though it is so hard not to feel bitter that little Greg couldn’t have lived to rejoice with the other two,” Frances wrote, “we just have to accept it as the Lord’s will and we know his death wasn’t in vain as it has given these two children another chance to live and no doubt many more. May God bless and guide you in the wonderful work you are doing.” A half a century later, as both a doctor and father, the grace and nobility of Frances Gittens’s Midwestern stoicism captures my own heart. Could anything more poignantly capture that nascent era of cardiac surgery than this mutually bittersweet exchange between doctor and family?

Initially Lillehei’s continued success with cross-circulation seemed to make him the unquestioned winner of the ethical debate with Watson. Four months after that first success, however, good fortune completely deserted Walt Lillehei. In a period of nine weeks, he used cross-circulation in seven patients. Six died. Like Bailey and Harken before him, Lillehei was suddenly in danger of becoming an outcast in his own hospital. Blindfolded Lady Justice’s scale of ethics and fairness, once so heavily weighted toward Lillehei following the publicity surrounding Annie Brown, now swung toward Watson. Some cardiologists refused to send him patients. When nurses whispered “murderer” it echoed off every wall and down every corridor of the university. And then, just when things could not get worse, they did. In December, now reeling from failure to failure, Lillehei traveled to surgery’s most prestigious professional meeting, the annual American College of Surgeons meeting in Atlantic City. Completely suppressing the news of his string of recent failures, he chose to report another spectacular success. He had accomplished the first complete repair of tetralogy of Fallot, the most common of the “blue baby” congenital cardiac abnormalities. We will meet one of my patients with “tet” later, so for now I will just tell you that this surgery is an order of magnitude greater surgical challenge than repair of a septal defect, because the surgeon must also correct stenosis (narrowing) of the pulmonic valve (the valve between the right ventricle and pulmonary artery) and an aorta that is a misconnected to the left ventricle.

His scientific presentation began as a classic Lillehei tour de force. But at least one person who listened that day was not impressed. I have heard both hilarious and embarrassing comments erupt from attendees over years of scientific meetings, but never a single one that comes close to equaling what happened at Lillehei’s presentation. An unidentified heckler shouted from the audience: “Admit you have a vegetable in the hospital!”