Louisville Medicine Volume 63, Issue 8 | Page 13

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 11