back and relaxed for a minute. The plan was to open up the narrowed channel below the aortic valve by coring out as much solid tumour as possible, then close the hole in the atrial septum. I gave the order to go onto the heart–lung machine and proceeded to stop the empty heart with cardioplegia fluid. It lay cold, still and flaccid in the bottom of the pericardial sac. I gently pressed the muscle and could feel the rubbery tumour through the heart wall. By now I was sure that I couldn’t reach it all with a conventional approach and that there was little point cutting into the ventricle that his circulation depended upon purely on an exploratory basis. So I told myself, ‘Just do it.’ Plan B. The eureka option, one that had probably never been done before. The perfusionist began to cool the whole body down from 37°C to 28°C. The boy was likely to be on the bypass machine for at least two hours.
At that point I had no option but to share Plan B with the rest of the team. I would chop out the boy’s heart from his chest and, with it lying on a kidney dish full of ice to keep it cool, operate on it on the bench. Then I could twist and turn the thing as much as I needed to do a good job. I considered it to be a brilliant idea, but I had to work fast.
The process was equivalent to removing a donor heart for transplant then sewing it back into the same patient. Back in my research days I’d transplanted tiny rat hearts. This boy’s heart should be no problem, even if the anatomy was unusual, so I transected the aorta just beyond the origin of the coronary arteries, then the main pulmonary artery. By pulling these vessels towards me, the roof of the left atrium was exposed at the back of his heart. I cut through the atria, leaving all the large veins from the body and lungs in place, then, lifting the ventricles out, I left most of the atria in situ. It was then, as you’d do with a donor heart, that I placed the cold, floppy muscle onto the ice.
Now I could see the tumour within the outflow part of the left ventricle. I started to dissect it out, cutting a channel through it so that it would no longer obstruct the heart. The tumour’s rubbery texture was consistent with it being benign, making me optimistic that we had done the right thing. Both my assistants were shocked and mesmerised by the empty chest and were not assisting well. And the longer this heart remained without a blood supply, the more likely that it would fail when I re-implanted it. Frankly, the Australian scrub nurse was much sharper than these trainees, so I asked her to help. She knew instinctively what was required and injected the necessary pace into the procedure.
I was torn between just doing enough or making a radical job of it. But I wanted to tell the boy’s mother that I’d succeeded in removing all of the tumour so I pursued it into the ventricular septum, close to the heart’s electrical wiring system. I knew where this was situated in a normal heart, but its location was less certain in this case. After thirty minutes I infused another dose of cardioplegia solution directly into both coronary arteries to keep the heart really cold and flaccid, and fifteen minutes later the job was done.
I took the boy’s heart back to his body, aligned the ventricles with the atrial cuffs and started to sew it in. I was really quite impressed with myself, the journal article already half-written in my head. The re-implantation process also closed the hole in the heart, so – with luck – he was cured.
This part of the operation had to be fail-safe as these stitch lines would be completely inaccessible in a beating heart. With both atria joined up again it was time to re-join the aorta and let blood back into the coronary arteries. The heart would start beating again and we could warm the boy’s body up. All that was left to do was to reconnect the main pulmonary artery. By then the surgical assistants had also warmed up a bit, on familiar territory once more with the heart back where it belonged.
Usually a child’s heart starts to beat spontaneously and quickly when its blood flow is restored, but this one was too slow. What’s more, I could see that the atria and the ventricles were contracting at different rates. This told me that the conduction system between the two was not working, which is not good as a coordinated heart rhythm is much more efficient. The anaesthetist had already noticed this on the electrocardiogram but said nothing. After cooling, the conduction system often goes to sleep for a while then recovers spontaneously.
Ten minutes later and nothing had changed. I must have cut through the electrical bundle while dissecting out the tumour. Shit and derision. He’d need a pacemaker. This made me more anxious about another issue. A transplanted heart also loses its connection with nerves from the brain, nerves that automatically speed up or slow down the heart during exercise or changes in blood volume. This denervation, together with the disruption of the electrical conduction system, could be a real problem.
My earlier euphoria, optimism and self-congratulation quickly abated, and the young mother drifted back into my thoughts. This wasn’t a good time to lose focus. There was still air within the heart chambers and it had to be let out, so I inserted a hollow needle into the aorta and pulmonary artery. Air fizzed out of both. When air entered the uppermost right coronary artery the right ventricle distended and stopped pumping.
We needed another fifteen minutes on the bypass machine for the effects to wear off. During that time I put temporary pacing electrodes on the right atrium and ventricle. We’d control his heart rate until the cardiologists could implant a permanent pacemaker. Gradually the heart function improved. Obstruction gone, lungs relieved of congestion, his life relieved of heart failure and breathlessness. Or so I hoped.
The boy’s pulse rate was only forty beats per minute, less than half of what it should have been. We increased that to ninety with the external pacemaker, and with this improvement the blood started to well up from behind the heart. I assumed that this was persistent bleeding through my stitching, so I told the perfusionist to turn the bypass machine off and empty the heart while I lifted it up to inspect the join. Nothing. It looked great. No leak.
When we restarted the machine thirty seconds later there was more blood. I inspected the joins of the aorta and pulmonary artery. No leak there, either. Eventually my first assistant spotted oozing from the aorta. The needle used to evacuate air had gone through the back, making a small hole. This would be inconsequential when blood clotting was restored, so we separated the boy from the heart–lung machine and closed the chest.
I didn’t have long to reflect on our success as a message came in from the adult cardiologists. They had just admitted a young male following a high-speed road-traffic accident. He’d not been wearing a seatbelt and his chest had impacted against the steering wheel with great force. He was in shock and his blood pressure could not be restored by fluid resuscitation.
Chest X-rays at the referring hospital had shown a fractured sternum and an enlarged heart shadow, and the veins in his neck were distended, suggesting blood under pressure in the pericardial sac. Not only that. The echocardiogram showed that the tricuspid valve, between his right atrium and ventricle, was leaking badly, hence the persistently low blood pressure and severe shock. The man needed urgent surgery, and could I please come and see him before it was too late?
I was distinctly uneasy about abandoning the boy but there was no choice. Leaving the operating theatre complex I found the mother sitting cross-legged in the corridor, alone and desolate. She’d been waiting there for five hours, and I sensed that she was about to implode mentally, her emotions bottled up for too long owing to her inability to communicate for whatever reason. And finally we’d taken away her bundle of rags. She saw me, sprang to her feet and panicked. Was the operation a success? I didn’t need to speak. Our eyes met again, pupil to pupil, retina to retina. My smile was enough, and with it the message that her son was still alive.
Bugger protocol and the audience of cardiologists. I needed to show her some affection so I held out a sticky hand, wondering whether she’d take it or remain aloof. This act of kindness unlocked the tension. She grasped it and began to shake uncontrollably.
I pulled her in and held her tight, as if to say, ‘You’re safe now, we won’t let anyone harm you any more.’ When I let go, she held on tight and started to weep uncontrollably, waves of emotion discharging onto the hospital corridor and leaving my Saudi colleagues standing in an embarrassed silence. It took a while to calm her, and they were becoming increasingly anxious about their trauma patient.
I told her that her son would