Heart Surgery 101

In 2005, I was asked to write a piece for KnowledgeNews.net. This piece is copied below, with a few minor additions. It was prompted by the fact that former President Bill Clinton was undergoing a second open heart procedure. The piece was titled Bill Clinton’s Heart* and began like this:

“Today former President Bill Clinton will reenter the operating room, and surgeons will reenter his chest-fixing problems created when they did coronary bypass surgery last year. Surgeons are never happy about revisiting previous work sites. Once violated, your body’s tissues heal with scarring, and scar tissue obliterates the nice, neat, anatomical planes that make most surgical operations predictable.”

It’s purpose was to answer this question:

“How will President Clinton’s doctors do their delicate work? How does heart surgery really work?” Here is how, and even 17 years later the setting and procedures are pretty much the same, though the technology and materials have all continued to improve.

Setting the stage

The patient lies in the middle of the cardiac surgical suite, flat on his back under bright lights, painted with an ochre iodine solution from neck to knees, then draped in multiple layers of sterile plastic and cotton. A vertical screen separates his head and neck from the site of the surgical action.

Behind this screen, the anesthesiologist does his magic, infusing a cocktail of oblivion­ inducing drugs into the patient’s veins, inserting a tube down the windpipe, and ventilating him with a mixture of gases that keep consciousness mercifully at bay. On the patient’s left side, the pump team sets up shop, with a technician seated behind a low, rectangular stainless steel machine the size of a large desk. He’s all about plumbing, preparing the tubes that, within the hour, will carry blood from the patient’s stilled heart to the machine, through a cylinder where the dark purple blood picks up oxygen and turns cherry red, and then back again to the patient’s aorta for distribution to the body. Raised over the end of the table is a mammoth tray of tools–surgical hardware.

Getting in

The surgeon and scrub nurse wait on the patient’s right, the surgical assistant on the left. With one vertical slice down the middle of the chest and a buzz of the saw down the center of the breastbone, or sternum, the chest wall is breached.

The surgeon wedges a nifty little tool into the sternal split, and proceeds to crank open the chest. (At the end of the surgery, he will use something that looks like a meat hook to wind up the wire sutures that pull the edges of the bone back together. And later write a prescription for enough narcotics for several weeks.) As the bone comes apart, a shiny pink pillow puffs up from below, filling the gap. This is the lung, protected in a slippery, clear envelope called the pleura, which lines the inside of the chest wall and the outside of each lung, letting the lung slide friction-free as it expands and contracts.

With the bony gap widened to six or seven inches, the surgeon removes the spreader and gently pushes aside the right and left lungs, covering them in wet, protective cloths. He is now in the middle compartment of the chest, the mediastinum. There, in the center, in a protective, transparent little envelope called the pericardium, is the heart–a purplish, muscular little fist of an organ in its healthy state, pumping away with a powerful twisting contraction. Of course, since we’re doing heart surgery for a reason, it might be a pale, flabby bag, draped in yellow fat, contracting with a weak little squeeze.

Getting the Job Done

Getting in is the standard part. What happens next depends on what the patient needs. Sometimes it’s a new valve inside the heart, or maybe two. Sometimes it’s bypassing diseased coronary arteries on the surface of the heart with an artery brought down from the chest wall and attached beyond the blockage, or with a piece of a vein from the patient’s leg attached at one end to the aorta and at the other end beyond the blockage. Either way, the stitch work is so tiny that the surgeon wears glasses with little microscopes on the lenses.

Sometimes a bypass can be done without stopping the heart, and the surgeon sews in rhythm with the beat. But most times, the surgeon has to re-plumb the body, sending un-oxygenated blood from the right side of the heart out to the mechanical pump and depending on the pump technician to run the machine and send the blood back to the aorta. Then the surgeon stops the heart with a mixture of drugs, letting it lie peacefully in the center of the chest while the repairs get done.

Getting Out

Going on the pump and coming off the pump can be white-knuckle times. Sometimes there is trouble restarting the heart. Sometimes the patient has to go back on the pump. But if all goes well, backing out is largely the reverse of getting in, with many checks in place. All the tools and all the gauze sponges used for mopping up must be back where they belong (it’s surprisingly easy to lose things in a blood-soaked operating field). The inside of the chest has to be dry (no leaking of blood from anywhere). Even then, tubes are left in place in the chest to let oozing fluids drain to the outside for the first few days of healing. These come out several days later, with a hard yank and a stitch or two to close the hole. Then the sternum gets pulled back together with wire – it stays in there permanently. If the surgeon likes music in the operating room, and all has gone smoothly, the music sometimes gets changed to something a little livelier, and the skin gets sewn up. The surgeon’s work, he hopes, is done. It’s nature’s time to go to work and smooth over all the cuts and stitches.

*KnowledgeNews, Thursday, March 10, 2005

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