Gettysburg Medical News
 The Clinical View
 by P.E. Hoffsten, MD
18 May 2005

FIFTY YEARS OF OPEN HEART SURGERY

            The gentleman was 48 years old and a very healthy, robust law enforcement officer equal to the physical requirements for handling rowdy and resistant tavern patrons.  He took no medications and his blood pressure was normal.  He was not a smoker and his cholesterol had always been normal.  He could run the mile and a half in 12 minutes and had a weight in the ideal body mass index range.  In summary, there was no reason for this gentleman to have any vascular problems.

            One morning he was walking downstairs and about 5 steps from the bottom, he suddenly collapsed and fell to the floor 5 steps below.  Fortunately, there was no major injury but he could not get up because his left leg simply didn’t work and his left arm was very weak.  Unaccustomed and opposed to seeing doctors (standard South Dakota male behavior), he decided not to call for help and instead struggled over to the couch and pulled himself up on it with his right arm and leg.  He sat there for awhile and slowly the function in his left arm and leg returned.  His wife later came home and she was the one who brought him to the clinic for further attention.  By the time he arrived, there was residual weakness in the left leg but no other abnormalities were noted.  He did not have a headache.  CAT scan of the head was done and it ruled out the possibility that he had a stroke.

            The next step in evaluation was called an echocardiogram in which sound waves are used to draw a picture of the entire structure of the heart.  It was found that he had a defect in the wall between the upper chambers of the heart.  This is called an atrial septal defect.  It is frequently not diagnosed until the person is an adult and seen for concerns about shortness of breath.  Very rarely as in this gentleman, the abnormality will present suddenly and dramatically because a blood clot from his leg can run through the hole in the heart and lodge directly into the brain.  In a normal individual, a little blood clot from the leg will lodge in the lungs and very often cause no symptoms at all as it resolves.  But on this occasion in this gentleman, the clot had lodged in an artery on the right side of his brain.  Fortunately, the clot broke up and dissolved over the course of several hours and there was no permanent abnormality.

            He was referred to Mayo Clinic where he underwent open heart surgery and the defect in his atrial septum was surgically corrected.  He continues now in good health completely recovered and the risk of a recurrent event such as happened to him walking down the stairs has been dealt with.  That surgery was so routine that he was in and out of the hospital in four days and returned to work within a month.  But it wasn’t like that 50 years ago.

            The first such surgeries done with the heart and lung machine were performed by Dr. John Kirklin at the Mayo Clinic in the mid 1950’s.  His first surgeries were done on children who had large atrial septal defects which were most frequently fatal prior to the children ever reaching first grade.  His publication in 1955 was heralded as miraculous. That he saved 4 of the 8 children was wonderful.  A 50% mortality for this surgery today would be prohibitive and the program would be shut down but then the medical community accepted the result as a glass half full, not half empty.

            In today’s practice, there is less than a 1% mortality in surgically correcting atrial septal defects.  Multiple other surgeries to correct other types of defects were subsequently developed using the heart/lung machine.  Today, one of the most commonly performed surgeries is coronary artery bypass with hundred of thousands of procedures done annually.  These surgeries are performed to save lives or to improve and maintain the quality of life that the person already has.  We owe a special salute to the pioneering surgeons at Mayo Clinic who first developed the techniques 50 years ago that we use so commonly today.

            But to keep perspective, a side note is in order.  In the past several years, a study was done on patients who had refused open heart surgery.  These were elderly individuals who had severe coronary artery disease and were strongly advised to have open heart surgery.  For reasons of their own, they refused the surgery.  They were then approached by a team of physicians who offered them an alternative of taking a medication called an atorvastatin at a very high dose of 80 mg daily.  Subsequent followup compared the group that had refused the surgery to those individuals who had said that they would go ahead with the surgery and had it done.  It was seen that there was actually an advantage and better result in the group that took the large dose of cholesterol lowering medication.  Granting that large doses of atorvastatin maybe associated with a muscle aching syndrome, liver abnormalities, and vague abdominal discomfort, the solution to coronary artery disease is still not perfected.  Medical progress is unending and in years to come an even better solution than surgery or atorvastatin will be forthcoming.  Thus far, we have no pill that will correct an atrial septal defect and surgery is still the treatment of choice.  But surgery still must be looked upon as a highly successful medical endeavor for the law enforcement gentleman above who had his atrial septal defect fixed and is spared from further threats of stroke.