Surgery Summary

Happy Anniversary, David!

Two years ago today David had successful open-heart surgery to repair his AV Canal defect, at Children’s Healthcare of Atlanta. I have written plenty about what the (emotional) experience was like for Matt and me. This is a summary of what David went through physically – some of it is hard to read, and the pictures are hard to look at, but this is everything we had to see and think about, so I’m not too sympathetic:

This is an article in the online magazine for the University of Texas. It is sort of worshipful, in the way a college magazine is going to be about an alum and chief surgeon. This was not David’s doc nor his hospital, but I imagine it’s pretty similar. The images are all stock photos, none are of David, nor did they accompany the article:

Excerpts from “To Save a Child’s Heart: Chuck Fraser and the Unbelievable Life of a Pediatric Heart Surgeon,” Tim Taliaferro, Alcalde: 

“They keep it meat-locker cold in the O.R. It smells of sterilizing chemicals. The bypass machine, a maze of tubes and tanks, whirs quietly next to another machine that keeps the temperature of the patient’s blood below freezing, inducing hypothermia. It hums like a refrigerator. Several monitors show a continuously updated bank of color-coded numbers with coordinating line graphs. The surgeon’s saw, high pitched at first, drops several octaves when its teeth meet breastbone.

Today’s operation, a complete atrioventricular canal defect  surgery, is a complex one, even for Charles Fraser, BA ’80, chief of congenital heart surgery and cardiac surgeon in charge at Texas Children’s Hospital in Houston … Fraser likes his operating room silent. He doesn’t tolerate chit chat. You can feel the force of his concentration, a total, all-consuming focus. He’s a meticulous surgeon, preferring to make his way deliberately rather than quickly through the layers of flesh surrounding the heart. When he gives directions to his assistants it’s in that nearly inaudible voice one stop above a whisper. Everyone’s on their toes. He gets everyone’s acknowledgement before stepping up to the table, crossing his left foot over his right, and holding out his hand. “Scalpel,” he says.

… Every heart surgery has four basic steps. The first involves opening the chest by cutting through the breastbone. Step two is getting the patient on bypass. For a surgeon to open up a heart, he or she must stop it, requiring a machine to then circulate and oxygenate the body’s blood. They call it bypass because the surgeon will insert tubes into the aorta and the inferior and superior vena cavas that will divert or bypass the blood away from the heart. Step three is stopping the heart and repairing it. Step four is getting off bypass and sewing everything back up.

Each step takes considerable time, and each has its particularly tricky moments. Choosing the size of the bypass tubes is one such moment: a tube that’s too big could damage the artery or vein, while one that’s too small might hinder bloodflow. And moments before you begin the bypass, the patient must be given blood thinners, which means from that point on any cut or puncture will be much harder to stop from bleeding uncontrollably.

Once the patient gets on bypass, the room goes totally quiet. The monitors that had been softly beeping go mute, and after an injection of potassium into the surrounding coronary arteries the heart very suddenly ceases beating. Now, with one quick movement, Fraser slits it open.

Even though he’s seen the insides of hundreds of hearts and has seen many scans of this one, Fraser can’t know exactly what he’ll find until he looks inside. No two hearts are exactly alike, and when dealing with congenitally defective hearts, anything is possible.

… Yet something happens the first time you peer into an infant’s open heart, formerly beating, currently stopped, while a surgeon manipulates its innards, correcting with scalpel and stitch what went wrong when some tiny strands of genetic coding crossed. The sight defies belief. This isn’t a real 5-month-old on this operating table, with its chest sawed open and its strawberry-sized heart sliced down the center — it can’t be.

… All these things hit you as you watch the painstakingly delicate handiwork a heart surgeon must perform to correct a problem without causing a new one. Infant hearts are tiny, the arteries and veins smaller still. There’s little room to maneuver the sharp surgical tools. The heart is bloody and slippery, and manipulating its shape or orientation to get at the chamber that needs attention calls for an elaborate system of strings, which must be passed through sections of heart muscle like a marionette then pulled gently to roll the organ left or right, up or down. Meanwhile, the baby’s life hangs in the balance.

On his way toward the heart, Fraser had cut a small piece of the pericardial sac, which surrounds the heart and lungs. From that he’ll create a patch to separate the two atria, another the two ventricles, and repair two valves that let blood into the heart. Measurement after measurement, stitch after tiny stitch, Fraser goes to work. His hands move rapidly and with purpose. He changes instruments often. An assistant squirts his hands down to keep the latex gloves from sticking. There are a few false starts, a couple of darnits uttered, but in time the patches are in and he stitches the heart back up. Three steps down, one big one still to go.

… Every time they try to back off the bypass, the patient responds poorly. The problem doesn’t appear to have to do with the heart, which is beating fine. Apparently the lungs are to blame.

Fraser seems mostly frustrated at not being able to do something. There doesn’t appear to be a surgical fix for the problem, so he must stand there, his hands restless, watching the monitor, hoping in the seconds between each update that the numbers will improve.

As the minutes turn to half-hours, the experience drives home what an audacious idea the notion of heart surgery is. There’s no such thing as a minor surgery. It is risky, intrusive, Promethean work trying to fix what nature got wrong. And even the very finest surgeons in the world sometimes get stumped.

Fraser tries again to back off the bypass, this time in smaller, slower increments. Ninety percent. Stop, wait. A few beeps and a slight downward slope on the graph. Then steady. Now 85 percent. A few more beeps but no crisis. Slowly, and with caution, they back off the bypass completely, and in time Fraser is satisfied that the patient is stable. He begins the long, slow effort to stitch up the child’s chest and wire shut its sternum. At 6:15 p.m., he finally steps away from the operating table for the first time.

When surgery goes well, and Fraser manages to fix and restart the heart, ease the child off of bypass, and sew up its chest; and when, after eight nonstop hours of intense concentration, he finally steps back from the operating table; and when, hours later, the infant opens its eyes and sees its parents’ faces, the whole episode seems, in a word, miraculous.”

To see David's surgeon, click here

We have had sort of a … not love-hate, but maybe love-dislike, relationship with both the surgeon and David’s regular outpatient cardiologist, Dr. Aaron. For the record, they both have fallen into the “love” category for over a year now. We totally acknowledge any dislike could be justifiably responded to with, “Hey, don’t shoot the messenger.” We met them both on two of the most difficult days of our lives (getting David’s diagnosis, and the surgery) so there may always be some degree of distress associated with them, no matter how great they are. And they are great, both of them. Hey, docs: You are the best at what you do, and we can’t thank you enough. Our beautiful little boy is doing so well, and you’ve both had a big part in that.  

I'll close with this image because Dr. Aaron told us before we left for Atlanta it was difficult to predict success because even with the best echo equipment, "the surgeon doesn't really know what he's got, until he's got the heart in his hands." This is confirmed by one of the paragraphs above, but at the time it was a really hard thing to hear. And of course David's heart was in his body the whole time, but this is still how I think of it.