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King of hearts
When a tiny baby’s life hangs in the balance, a heart surgeon’s emotional, physical and intellectual strengths are tested to the limit. In an extract from his new book, surgeon Stephen Westaby talks through a pioneering operation and its far-reaching cons
The surgeon Stephen Westaby details one of his most delicate operations: on a baby’s heart
The finest of margins separates life from death, triumph from defeat, hope from despair – a few more muscle cells, a fraction more lactic acid in the blood, a little extra swelling of the brain. The Grim Reaper perches on every surgeon’s shoulder and death is definitive. There are no second chances.
Woody Allen famously said, ‘The brain is my second favourite organ.’ I had the same affinity with the heart. I liked to watch it, stop it, repair it and start it up again, like a mechanic tinkering with an engine beneath the bonnet of a car. What is so fascinating about the human heart is its movement. The rhythm and efficiency of the thing. The heart beats more than 31 million times in a year, pumping 6,000 litres of blood daily to the body and lungs. Each heart is different. Some fat, some lean, some thick, some thin. Just never the same. When I finally understood how it worked, the rest just followed on. More hobby than job, and more pleasure than chore, heart surgery was simply something I was good at. Monday February 15, 1999, 3.45am. No one calls with good news at night. I’d been in Australia for just 13 hours after a 20-hour flight. In pitch darkness I scrambled across my hotel bed and knocked the receiver to the floor. The call was lost. I slipped back into sleep, courtesy of melatonin tablets and the bottle of Merlot I’d drunk at dinner. Ten minutes later the phone rang again. This time I fielded it successfully, but I was irritated. ‘Westaby? This is Archer. Where are you?’ Nick Archer was my superb paediatric cardiolog y colleague at the John Radcliffe Hospital in Oxford. ‘I’m in Sydney. It’s t he middle of the night – what’s the problem?’
‘Steve, I’m sorry, but we need you to come back. We have a sick baby with ALCAPA. The parents know of you and want you to do the surgery as soon as possible. She has bad heart failure and is as good as we can make her. The ventricle is poor.’
‘OK, I’ll fly back today. You tell the team we’ll do it tomorrow, whenever that is.’
It was high summer in the southern hemisphere and early morning light had just begun to penetrate the curtains. Further attempts to sleep were pointless. I stepped on to the balcony and gazed out at one of the finest city vistas in the world.
In Oxford a tragedy was unfolding for a little family. Born in August 1998 by caesarean section, Kirsty was a beautiful six-month-old baby girl in whom fate had installed a lethal self-destruct mechanism, a miserable detail that seemed destined to end her life before her first birthday.
ALCAPA is an abbreviation for anomalous left coronary artery from the pulmonary artery, an isolated and exceptionally rare congenital anomaly in the overall complexity of human anatomy. Simply put, it’s bad wiring. Both coronary arteries should rise out of the aorta and supply the heart muscle with welloxygenated blood under high pressure. They should never be attached to the pulmonary a r ter y, as t his has bot h low pressure and poor ox ygen content. Early sur v ival wit h ALCAPA therefore depends on the development of new ‘collateral’ blood vessels between t he normal r ight coronar y ar ter y and t he misplaced left coronary artery. But eventually these are insufficient to sustain blood flow to t he main pumping chamber. Muscle cells deprived of oxygen die and are replaced by scar tissue, leaving the baby to suffer what are in effect repeated, painful heart attacks. Then the hear t prog ressively fails and the lungs become congested with blood, leading to breat hle s snes s a nd ex haust ion. Even during feeding.
Because ALCAPA is so rare, the diagnosis is seldom made until the infant is terminally ill.
At first everything seemed normal for Kirsty, but not for long. In the womb the pressures and oxygen content of the aorta and pulmonary artery are the same, so Kirsty’s tiny heart was safe. After birth the circulations to the body and newly expanded lungs separate, and both pressure and oxygen content in the pulmonary artery fall.
So, in cases of ALCAPA, both blood flow and oxygen content in that critically important left coronary artery fall precipitously, too. Kirsty was grunting even during the first attempt to breastfeed in the hospital, and her mother Becky noticed beads of sweat trickling from the bridge of her baby’s nose. The effort of feeding repeatedly made her fractious and distressed. This was distinctly different from how her son had been, so Becky asked for a paediatrician to review Kirsty. She was told that there was nothing to worry about. Becky had little choice but to take her home. Within weeks Becky was certain that something was seriously amiss. During every feed the baby sweated and vomited.
Kirsty str uggled for breath, clenched her little fists and screamed until she was puce in the face. Together they made many visits to the GP, but they always received the same non-committal reassurance – tense, unpleasant encounters. Becky was deemed neurotic and unable to cope. All of the common paediatric problems were excluded. Family and friends offered rational explanations – it must be colic and would get better. But with her husband working abroad, Becky became more and more anxious. Kirsty wasn’t gaining weight. She had a pasty, washed-out look and a cough like a dog’s bark. In reality this baby was suffering repeated small heart attacks with excruciating chest pain that she could neither communicate nor understand.
Becky’s anxiety and frustration now turned to desperation. Every instinct told her that if she didn’t push further something dreadful was going to happen, so she drove directly to
Kirsty wasn’t gaining weight. She had a pasty, washed-out look and a cough like a dog’s bark. This baby was suffering repeated small heart attacks
the accident and emergency department of her small local hospital. They were seen by a sympathetic female doctor who had children of her own. She referred them on to a larger city hospital for review by the on-call paediatrician. It was a bitterly cold, frosty night and they were left sitting in an unheated hospital corridor for several hours. Becky frantically struggled to keep Kirsty warm but she became prog ressively more limp and grey. Eventually, late into the night, they were seen. The first junior doctor suggested bronchiolit is. Bronchiolit is seemed to be the only paediatric diag nosis t hese doctors had hea rd of. When Becky refused to leave without a chest X-ray she was told off for her unreasonable attitude.
The sad pair were dispatched, unescorted, down poorly lit corridors and icy outside walkways to find their own way to the X-ray department. It was well past midnight when they returned, clutching the picture, which Becky presented to a nurse. They were parked once more. Another 30 minutes passed, then came a dramatic shif t in attitude from the hospital staff. Kirsty and Becky were ushered into a cubicle with different doctors. Now there were hushed voices, grave expressions, and nurses bringing drips and drugs. This was even more f r ightening t han being ig nored. The now embarrassed nurse took Becky aside to explain that Kirsty was being transferred to the specialist children’s heart unit in Oxford. By ambulance this time. Suddenly she was too sick to remain unsupervised.
So what did the X-ray show to trigger this frenzy of activity? That Kirsty had a massive heart was immediately obvious on the X-ray film. When the staff were pressed about her previous X-rays at the same hospital, Becky was told that the heart shadow had been misinterpreted as fluid – ‘Sorr y, but it’s an easy mistake to make.’
When they arrived in Oxford, the paediatric cardiolog y registrar met the ambulance and took them directly to a ward packed with children with serious heart problems and beeping monitors – a hive of activity in the depths of night. Nick Archer arrived at 3am. An ECG and blood tests were done quickly, then the echo machine was brought in to image Kirsty’s heart chambers. The left atrium and ventricle were both enlarged, the ventricle dramatically so. This explained the heart failure and accounted for the striking chest X-ray. In little more than an hour the cardiolog y team established that Kirsty had severe heart failure from multiple heart attacks. Parts of the left ventricular wall now consisted of thin scar tissue interspersed with poorly contracting muscle, a rare condition in an infant but one that provided the likely diagnosis. One further test was needed. A cardiac catheter would confirm the diagnosis but would require a general anaesthetic, so she’d have to be in much better condition before proceeding.
It was a full five weeks before Kirsty was considered fit enough for the cardiac catheter. The night before, she was christened in her cot by the hospital chaplain; the doctors, nurses and other families gathering around the bed to support the family. Everyone knew what the procedure would show. Becky and her husband stayed by the cot the whole night long, terrified that Kirsty might slip away. In the morning, without having slept and paralysed by fear, Becky dressed her baby in her best pyjamas and tied a bow in her hair for her trip to the catheterisation laboratory.
Once I was on the plane home I started to sketch the anatomy of Kirsty’s aor ta, pulmonar y ar ter y and abnormal lef t coronary artery. I knew that the current techniques in operations for ALCAPA had limitations and a substantial failure rate, so I used my time during the flight to work out an alternative. By the time we were cruising high above Java I’d designed my new operation.
Last on, I was first off the plane back in London. As I waited for the air bridge to connect and the doors to open, the cabin services director handed me a bottle of champagne, wished me luck and whispered, ‘You operated on my sister’s baby.’ Small world. I called my colleague Katsumata when I got back to Oxford and asked him to bring Kirsty’s parents to my office with a consent form. The cardiac catheter had shown precisely what Archer had suspected. Kirsty needed surgery as soon as possible.
When we met, Becky was trembling uncontrollably. Finally, after weeks in hospital the time had come – the day she might lose her baby. I described my planned operation to the team and explained why I felt it would be an improvement on existing techniques. The new left coronary artery would be constructed with a flap of aor tic wall that would sit below a corresponding pulmonary flap to make a tube, the latter containing the misplaced origin of the left coronary artery at its apex.
The product would be a new coronary artery deliver ing high-pressure, well-ox ygenated blood directly from the aorta, where it should have come from in the first place. Blood fully saturated with oxygen would then supply the failing heart muscle and prevent further heart attacks. Katsumata was so intrigued and excited by my proposed approach that he rushed off to call the hospital’s film crew.
Becky’s shaky hand signed the consent form and I walked back with them to the children’s ward. When we reached the cot Kirsty’s heart failure was worse than I imagined, indeed the worst I’d ever seen in any child. She was emaciated, with virtually no body fat, her heaving ribs and rapid breathing a consequence of her congested lungs, and her abdomen swollen with fluid. Without immediate surgery she’d be dead within days.
Although a voice in my head screamed, ‘Oh shit,’ my mouth said, ‘I’ll go to theatre now.’
‘Do you really think you can get this baby through?’ asked Kate, the anaesthetist. I didn’t reply, bidding a cheery ‘Good morning’ to the nurses and perfusion team [responsible for the heart-lung machine] in the operating theatre, then went to the coffee room. I wanted to avoid seeing Becky leave Kirsty with strangers.
When I returned, Kirsty was already on the operating table, covered in green drapes held in place with an adherent plastic drape. All that was visible were her bony little chest and swollen abdomen. Heart
The night before the procedure, Kirsty was christened in her cot by the hospital chaplain; the doctors and nurses gathering round to support the family
surgery needs to be an impersonal, technical exercise. I joined Katsumata and my 6ft 6in Australian colleag ue Matthew at the scr ub sink. We scrubbed in silence as the film camera was carefully positioned next to the operating lights. There was a palpable buzz. We were about to do something novel, esoteric, risky. There was no bleeding as I drew the scalpel blade along the skin over Kirsty’s breastbone. In shock, her skin capillaries had shut down to divert blood to vital organs. Next the electrocautery cut through the thin layer of fat on to the bone, producing its characteristic buzzing noise accompanied by a whiff of burning as the current cauterised the blood vessels.
The electric saw cut through the leng th of her sternum, exposing bright-red bone marrow. We used a small metal retractor to crank open her tiny chest, bending and stretching the joints between the ribs and the spinal column. The electrocautery continued its messy but vital work, cutting through the fibrous pericardial sac to expose t he hear t, st rawcoloured fluid pouring out and being drawn away by the sucker. Meanwhile the other members of the team worked on silently. Kate gave heparin to stop Kirsty’s blood from clotting in the heart-lung machine, the perfusion team set up the complex array of tubing, pumps and oxygenating equipment to keep Kirsty’s body alive when her heart was stopped, and the scrub nurse, Pauline, concentrated on having the correct surgical instruments ready to slap into my palm. As we pulled up the edges of the pericardial membrane to display the heart, Katsumata audibly drew breath and murmured, ‘Oh shit.’ Things were even worse than we’d thought. What should have been a walnutsized heart was revealed to be the size of a lemon. The enlarged right coronary artery was obvious, its many dilated branches crossing over towards the left ventricle. While the right side of the heart pumped vigorously against raised pressure in the lungs, the left ventricle was hugely dilated and barely moved.
Having exposed this heart I began to question the wisdom of attempting such a complex operation straight off a day-long flight. But now I was committed there could be no turning back.
Tiny pipes were inserted to connect her to the heart-lung machine, and I then gave the sig nal to go on bypass. Brian, the perfusion technician, turned on the roller pump and the heart gradually emptied. At this point technolog y had taken over, diverting blood away from her lungs and into the synthetic oxygenator. With her empty heart still beating I cut t hrough t he pulmonar y a r ter y above t he origin of the anomalous coronary. There was the opening to the vessel, like the pearl in an oyster. Now we had to connect it without tension to the high-pressure aorta that lay almost an inch away. The conventional method was simply to tr y to stretch and re-implant the origin of the vessel into the side of the aorta. But t his of ten resulted in t hrombosis and blockage, so I pressed on with my new technique. This delicate exercise could only be achieved by clamping the aorta and temporarily stopping all blood flow to the heart.
We’d protect the muscle by infusing cardioplegia fluid directly into both coronary arteries, flushing all the blood out and collapsing the ventricle like a punctured football. This induced state of inactivity, common in heart surgery, is reversed simply by removing the clamp on the aorta, which allows blood from the heart-lung machine to flow back into the coronary ar teries. For the reconstruction of this tiny vessel, the stitching had to be precise, accurate and watertight.
The procedure went well. Just 30 minutes after the heart was stopped, the conjoined flaps restored Kirsty’s coronary artery anatomy to what it should have been. As the clamp was removed, bright-red oxygenated blood – rather than deoxygenated blue blood – flooded the left ventricular muscle. Her heart changed from a pale-pink colour to deep purple, then became almost black in parts. Before reconstructing the pulmonary artery we checked that there was no bleeding from the lines of stitching behind it. Soon the electrocardiogram showed uncoordinated electrical activity, and the heart stiffened with renewed muscle tone.
We used an electric shock directly through the muscle to restore normal rhy thm. Ten joules – zap! The heart was now motionless but we expected a normal rhythm to resume at any moment. It didn’t. The purple ball fibrillated and squir med and t he anaest het ist’s head popped over the drapes to request the obvious – ‘Shock it again!’ We did and the same thing
Having exposed this heart I began to question the wisdom of attempting such a complex operation straight off a day-long flight. But there could be no turning back
happened. It wasn’t coming back. This was serious electrical instability caused by the scar tissue, so we gave drugs to stabilise the muscle cell membranes. ‘Let’s give it more reperfusion time,’ I told Kate. Twenty minutes later we tried again. Twenty joules – zap! This time her little body levitated from the operating table and her heart defibrillated. Although it slowly began to beat, it was barely more than a flicker. Ominous.
While Kate and Brian worked together to check and optimise the blood chemistry, my gaze remained fixed on Kirsty’s pathetic little heart. The new coronary artery was fine – there was no kink in the tube and no bleeding. For the first time the left ventricle was receiving well-oxygenated blood at the same pressure as the rest of the body. But her heart still looked like an overripe plum and was barely beating at all. Moreover, the mitral valve was leaking badly. Although I heard myself telling the team to give it another half hour’s support on the pump, what I was really thinking was we’re stuffed, this heart’s had it; great operation – dead baby. I was starting to fade. I suggested that the cameraman should stop filming for a while because nothing was going to change, and asked Katsumata to come to my side of the operating table while I took a break. I removed my gown and gloves, and went to the anaesthetic room. Kate followed. ‘Can you repair the mitral valve?’ she asked me. ‘Don’t think so,’ I replied. ‘I’ll get Archer to warn the parents.’
I slumped on a stool and picked up the phone. One of the nurses put a coffee and doughnut in front of me. With her arm around my shoulder, she felt the cold sweat dripping down the nape of my neck. ‘I’ll get you a dry top,’ she said. In five minutes Archer was down from his outpatient clinic and at the theatre door. He didn’t need to ask. ‘Thought you might have trouble. Anything I can do?’
‘Take a look at the echo,’ I said. ‘The repair’s fine but the ventricle’s lousy. Mitral valve’s leaking. At this rate we’re not going to get off the pump.’ I wandered off to the loo.
When I got back, my brain had regained control. What, if anything, could I do to make things better? I was running out of ideas. The left ventricle was scarred, dilated and now globular – not the normal elliptical shape. This distortion had pulled open the mitral valve and prevented it from closing. As the left ventricle tried to pump blood around the body, as much as half of it flowed backwards to the lungs. Heart function is always temporarily worsened during surgery, but in Kirsty’s case it seemed terminal. I’d hoped that resting the heart on the bypass machine would help it to recover. It hadn’t. I went back to the operating theatre, scrub bed up again and switched with Katsumata. He said nothing, but looked crestfallen – a clear message. I asked Kate to start ventilating the lungs and told Brian to prepare to slowly ease off the machine.
At this point Kirsty’s heart needed to take over, other wise she’d die on the operating table. We all stared at the traces on the screen, hoping to see her blood pressure rise. It briefly reached half normal, but then fell away rapidly as the pump was switched off. ‘Shall we go back on?’ asked Katsumata. Watching the lef t vent r icle f l icker on t he echo, Br ia n questioned whether it was worth it. ‘She’s had it, hasn’t she?’ was t he real message f rom behind the drapes.
‘Let’s go back on, give it another half hour.’ This in itself was problematic, as a long bypass time always lessened the chance of recovery. Kirsty’s parents were waiting in the children’s ward – Archer had gone to warn them. When we called him back, Becky insisted on coming to the doors of the operating theatre complex with him. I knew that the prospect of her holding Kirsty’s emaciated and lifeless corpse was not far away.
Becky recorded her thoughts in her diary at the time: ‘Dr Archer sat us down. The surgeons were st ill t r ying but t he prospects looked bleak. We may lose her. Then he had to leave. By now my head was spinning. I remember feeling sort of drunk. This wasn’t the plan. If we waited patiently everything would be OK because that sort of thing only happens to other people. Then Dr Archer came back. He told us he was so sorr y. Ever y option had been exhausted. He would be arranging for us to go and hold her to say goodbye. I could not bear the thought that when I saw her again she would be cold. My baby was so soft and warm. Smelt delicious, hair like velvet, hot f uzzy cheeks. I just kept thinking that my hear t would break if she was limp and cold. The t hought of Kirsty f ight ing for her life and nothing we could do. We might as well have been on the other side of the world.’
Iremember Becky saying, ‘Please save my little girl.’ I was poleaxed and said nothing. Archer looked desolate. I turned back to the sombre theatre, put on a new mask and scrubbed up again. Kate said, ‘Things are no better. Can we turn the pump off?’
‘No, I’m going to try one more thing. Turn the lungs off. Run the camera again.’ This was my last-gasp attempt. It was something that had never been done before in a child. The tension on the wall of Kirsty’s scarred left ventricle was elevated because of the size of the cavity. From a recent conference I knew that a Brazilian surgeon had made a series of failing adult hearts smaller when a tropical infection, Chagas disease, had weakened the muscle. The operation had been attempted for other types of heart failure patients in North America but was quickly discredited and abandoned.
This bold approach was Kirsty’s last hope. I was not going to risk stopping the heart again, so I took a glistening new scalpel and cut the beating left ventricle wide open from apex to base, just like unzipping a sleeping bag. I began in an area of scar, avoiding the muscles that support the mitral valve, and the filleted heart immediately fibrillated in response to cutting. This was fine because there was no risk of it pumping air. The inner lining of the heart was covered in thick, white scar tissue. To reduce the diameter of the ventricle I cut away the tissue on either side of the incision until I reached bleeding muscle, removing one third of the circumference of the chamber. In an attempt to stop the mitral valve from leaking, I sewed the central point of its two leaflets together, turning it from an oval to a double orifice structure resembling a pair of spectacles.
Then I sewed the muscle edges together with
Twenty joules – zap! Her little body levitated from the operating table and her heart defibrillated. Although it slowly began to beat, it was barely more than a flicker. Ominous
The heart looked like a quivering black banana. Not for a moment did I think it would ever start again – and nor did my colleagues
a double row of stitches to close the heart. In the end, this much smaller heart looked like a quivering black banana. Not for a moment did I think it would ever start again – and nor did my colleagues. They thought I was crazy.
Word of the bizarre operation in Theatre 5 soon spread. The curious gathered to watch and the camera kept on filming. We had to ensure that all air was removed from the heart, other wise it could be ejected into the blood vessels of the brain and cause a stroke. After that, all that remained was to defibrillate and try to restore normal heart rhythm. ‘We’re done,’ I announced. ‘Try 20 joules.’ Zap! The heart stopped quivering, and for what seemed like an age there was no spontaneous electrical activity. I poked the muscle with forceps and it contracted in response. This time there was a flicker on the blood-pressure trace.
Miraculously, the black banana had ejected blood into the aorta. Kate looked again at the echo. ‘It certainly looks different. Shall we try using the pacemaker?’ I was already sewing the fine pacing wires into place. We arbitrarily set the pacing box rate at 100 beats per minute and switched it on. I told Brian to cut back on the pump flow rate and leave blood in the heart to see if it would eject consistently. It did. What’s more, the echo showed that the mitral valve no longer leaked. I felt that we were in with a chance. Life depends upon physics and geometry.
It was now after midday. Kirsty had been on t he by pass machine for more t han t hree hours and we needed to get her off it. As if timed to perfection, her own heart rhythm suddenly broke through the pacing. Coordinated natural heart rhythm is much more efficient than electrical pacing, providing better blood flow and pressure.
It was like switching on a light in the operating theatre. Gloom changed to elation. My own adrenalin kicked in and the fatigue suddenly lifted. We gave Kirsty an infusion of adrenalin to help her heart take over from the bypass machine. Finally I gave the instruction to ‘come off slowly ’. We still expected her blood pressure to fade, yet the curiously re configured little heart kept on pumping. ‘Off bypass. I don’t believe it,’ said Kate. I looked over my mask at Katsumata. He knew that I’d had enough by now. ‘Let me finish,’ he said.
I took a last, disbelieving glance at the little black banana pumping away, then turned to the echo screen, where the incomprehensible flashes of white, blue and yellow were also reassuring, like a blazing fire. We could see blood streaming through the new left coronary and a double jet entering the left ventricle through them it ralvalv e–a curiously re configured baby’s heart that finally worked.
Katsumata made certain that there was no bleeding, then meticulously closed the chest. ‘Never been done before,’ he said, looking over at me. Soon afterwards Becky came down to the paediatric intensive care unit. She put her hand on Kirsty’s little foot and exclaimed, ‘It’s warm. It’s never been warm.’ When she started to cry I left. It had been a long day.
Kirsty survived. We followed her carefully over the next 10 years, using echocardiography to watch her heart develop. She was a perfect little girl, happy, outgoing and energetic, the only clue to her extraordinary internal metamorphosis being the faint stripe up the middle of her chest. When we felt she was mature enough to discuss it we asked for her permission to carry out a magnetic resonance imaging scan to show us how the remodelled heart had developed. What we found was extraordinary.
Apart from the double-orifice mitral valve, her heart appeared normal, as did her new left coronary artery. Only a thin scar showed the position of the line of stitches up the heart. Remarkably, all others cart issue had disappeared. The whole inner lining of her left ventricle had been pure white scar tissue – now all gone. This provided some of the first evidence that an infant’s own cardiac stem cells can regenerate heart muscle and actually remove fibrous tissue. Adult hearts cannot recover in the same way. But what if we could identify and culture stem cells that could do just this for an adult heart? Could it provide a solution for the hundreds of thousands of adult chronic heart failure patients with
coronary artery disease? I would eventually find out.
Now aged 18, Kirsty is a vivacious and athletic teenager, but had she died we’d never have known about this exciting possibility for heart regeneration. Her case could potentially save countless other lives.
Heart surgery has been a difficult road and a lonely destination. Despite best efforts some of my 12,000 patients took the fast track to heaven. How many I really don’t know. Like a bomber pilot I didn’t dwell on death. It was more than 300, fewer than 400, I guess.
My mentor in the US was the great Dr John Kirklin, who pioneered the heart-lung machine. Towards the end of his career he wrote: ‘After many years of cardiac surgery, with all its tests and challenges, and after many deaths that could not then be prevented, we gradually become a little weary and in some sense infinitely sad because of life’s inevitability.’
I wrote this book because I have reached that same point in a career spanning the rise and fall of the NHS. The pioneering days were highly competitive. Young heart surgeons were the thrusting blades of the medical world and we really did work constantly. In the States it was 5am ward rounds, operate all day, go to the research laboratory in the evenings, capped by night-time vigils beside the intensive-care bed. So what happened to heart surgery in the UK? Now we have the European Working Time Directive and a 48-hour week for trainees. Barely compatible with developing clinical experience and surgical dexterity. Next – after multiple hospital scandals – came the decision to publish surgeons’ death rates. Who would be a heart surgeon now? With long, taxing operations, anxious relatives, the nights and weekend on ca ll. Worse st ill, a healt h system entrenched in nonsensical bureaucracy with the reward of public exposure for a run of bad luck. Already 60 per cent of our children’s heart surgeons are overseas graduates.
In the final analysis, a profession that dwells upon death is unlikely to prosper – undertakers and the military aside. As Dr Kirklin emphasised, some deaths in cardiac surger y are inevitable. When a surgeon is focused on helping as many patients as his ability will allow, some will die. But we should not accept inconsistent teams, substandard facilities or lack of vital equipment. Otherwise patients die needlessly. The answer? Bury the blame-and-shame culture and give us the tools to do the job.
Now aged 18, Kirsty is a vivacious and athletic teenager; had she died we’d never have known about the exciting possibility for heart regeneration