The Heart Healers: The Misfits, Mavericks, and Rebels Who Created the Greatest Medical Breakthrough of Our Lives
401
The Heart Healers: The Misfits, Mavericks, and Rebels Who Created the Greatest Medical Breakthrough of Our Lives
401eBook
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Overview
At one time, heart disease was a death sentence. In The Heart Healers, world renowned cardiac surgeon Dr. James Forrester tells the story of the mavericks and rebels who defied the accumulated medical wisdom of the day to begin conquering heart disease. By the middle of the 20th century, heart disease was killing millions and, as with the Black Death centuries before, physicians stood helpless. Visionaries, though, had begun to make strides earlier. On Sept. 7, 1895, Ludwig Rehn successfully sutured the heart of a living man with a knife wound to the chest for the first time. Once it was deemed possible to perform surgery on the heart, others followed. In 1929, Dr. Werner Forssman inserted a cardiac catheter in his own arm and forced the x-ray technician on duty to take a photo as he successfully threaded it down the vein into his own heart...and lived. On June 6, 1944 - D-Day - another momentous event occurred far from the Normandy beaches: Dr. Dwight Harken sutured the shrapnel-injured heart of a young soldier, saved his life and the term "cardiac surgeon" born.
Dr. Forrester tells the story of these rebels and the risks they took with their own lives and the lives of others to heal the most elemental of human organs - the heart. The result is a compelling chronicle of a disease and its cure, a disease that is still with us, but one that is slowly being worn away by "The Heart Healers".
Product Details
| ISBN-13: | 9781466862555 |
|---|---|
| Publisher: | St. Martin's Publishing Group |
| Publication date: | 06/04/2024 |
| Sold by: | Barnes & Noble |
| Format: | eBook |
| Pages: | 401 |
| File size: | 4 MB |
About the Author
Read an Excerpt
The Heart Healers
The Misfits, Mavericks, and Rebels Who Created the Greatest Medical Breakthrough of Our Lives
By James Forrester
St. Martin's Press
Copyright © 2015 James ForresterAll rights reserved.
ISBN: 978-1-4668-6255-5
CHAPTER 1
A DAY LIKE ALL DAYS
A shocking occurrence ceases to be shocking when it occurs daily.
— Alexander Chase, American Journalist
EVERY DOCTOR HAS his favorite organ. Hannibal Lecter prefers the liver; I prefer the heart. Surely it is our body's hardest worker. Imagine performing 90,000 very forceful push-ups a day, with no time-out for rest. How is it possible, when few of us could clench and unclench our fist at that rate for even an hour? Try doing that for eighty years with not one second off for good behavior. Complex in structure yet simple in function, yet so perfect in performance, the heart is truly Nature's engineering masterpiece.
Midway in size between a baseball and a softball, its oblong football shape still fits nicely in your hand. Squeeze it. It feels firm and muscular but also hollow. Turn it around in your hands, looking at its surface. Three prominent coronary arteries with lots of branches spread over the heart's surface before diving into the muscle to supply all the heart cells with blood.
Since it feels hollow, let's open the heart to see what is inside. In the heart, as in architecture, form follows function. We see four separate chambers. The two chambers on the right (the "right heart") are responsible for collecting blood from the body and the pumping it to the lungs where oxygen is added. The two chambers on the left (the "left heart") are responsible for collecting oxygenated blood from the lungs and delivering it to all the organs of the body. The heart's structure reflects its dual collecting and pumping function. Both the right and left hearts consist of a thin-walled collecting chamber (ancients coined it the "atrium") and a thicker walled pumping chamber (the "ventricle").
But why does the heart contract about sixty times a minute when we are resting and as much as 180 times a minute when we exercise? What controls the pump? Specialized cells embedded in the right atrium (the blood-collecting chamber of the right heart) spontaneously emit an electrical impulse at about once per second at rest. The impulse causes the atrial muscle to contract. The contraction forces blood across a one-way valve between the atrium and right ventricle. At the same time, the electrical impulse travels also into the ventricle (the pumping chamber). So about two-tenths of a second after the atrium contracts, the ventricle is shocked into vigorous contraction. What a shrewd innovation by the celestial design committee! When it contracts, the atrium "loads" the ventricular pump with blood, and then two tenths of a second later the ventricle fires off, slamming the one-way valve shut and sending blood rocketing to the lungs. It's like the ticktock of a grandfather clock: the valve is opened, closed, opened, closed.
Exactly the same process occurs at the same time in the left heart, sending blood to the body's organs. Repeat that every second, and you have a pumping system that circulates oxygen to body's organs, and returns the deoxygenated blood to the lungs to be reoxygenated.
Because of the valve system, blood flows continuously in only one direction (it "circulates"). It's the same principle as the locks on the Panama Canal. When the inflow valves close, the outflow valves open. Like the needle of a metronome swinging back and forth, the two pairs of valves in the right and left heart open and close in perfect synchrony: the ticktock lasts a lifetime. And of course both the right and left hearts receive and eject blood through large vessels. The most important of these vessels is called the aorta, which delivers blood from the left ventricle to the entire body.
The muscle, valves, and electrical system do the work of the heart. Its fourth component, the coronary arteries, delivers oxygen-giving energy for all this hard work. The two coronary arteries, right and left, are the very first branches to come off the aorta; first dibs for life-sustaining oxygen goes to the body's most important organ. The coronary arteries send branches that cover the entire surface of the heart and also plunge deep into the heart muscle so that no cell is deprived of oxygen.
When the aorta delivers blood into each organ, the red blood cell that transports the energy-giving oxygen changes in color from bright red to dark blue. Now it's time to deliver the blood back to the lungs, add oxygen, and repeat the cycle. The blood from all the organs is collected in larger and larger veins and returned back to the right atrium where the process of reoxygenation begins anew. Arteries deliver blood; veins return it. It takes about sixty heartbeats to complete one cycle at rest.
The heart's oxygen delivery system functions like a perfect machine because its form (anatomy) is so ingeniously integrated with its function. The muscular pump consists of collecting and pumping chambers. Circular flow is created by its system of one-way valves. The muscle meets its own intense need for an energy supply by first delivering oxygen to itself through its coronary arteries. And finally the whole system is exquisitely sensitive to the needs of its client, the body. Need more oxygen because you are in Yosemite, running from a black bear? No problem. Your heart can quintuple the flow of blood in seconds by tripling the heart rate and increasing the vigor of ventricular contraction.
Now that you know how your own heart actually works, let's meet our first patient, who could one day be you.
* * *
ALONE WITH HER morning mug of coffee, Greta Adams stood on her patio trying to savor this daily solitary moment she cherished. Thirty-five years old, she loved the moist morning fog that rolled off the Pacific Ocean to be momentarily trapped in the hills above her home in Pacific Palisades, a small community northwest of Los Angeles. Each year nature repainted the canvas behind her, as the torrential rains and mudslides of February led to the explosion of yellow and purple mountain flowers of April, the now-green hills of June, and then finally the dry gray chaparral tumbling before the hot dry Santa Ana winds of September. How could anyone say California has no seasons?
This morning, though, the misty sea and mountain vista did not shake her free from a sense of foreboding. On most days her first thought was how to squeeze in an hour's brisk walk and jog in nearby Will Rogers Park just north of Sunset Boulevard. But jogging, which had been her physical release, was now her bondage. Several weeks earlier she first noticed the discomfort, like a knot in her shoulder. At first, Greta was not so much concerned as she was puzzled. At first she thought it was a muscle cramp from climbing the rope that hung from a tree in her backyard. "I am young and I am healthy," she reasoned. She had had her share of bumps and bruises over the years. Her thought seemed confirmed when she stopped her jog and the cramp rapidly disappeared. When it kept coming back on every morning run, she went to a massage therapist. Massage proved futile. When the knot extended to beneath her breastbone, she began to imagine more fanciful explanations. Could the moist salt air and the morning auto exhaust wafting over from Pacific Coast Highway cause chest pain? Could her discomfort be psychological, precipitated by her worry about a bully at Benjamin's school? No, it wasn't just in her mind, because the knot was now a small insolent fist, more insistent and more menacing with each run. It was time to see a doctor.
Greta and Tyler's drive to my office took her east on Sunset Boulevard past colossal mansions worth tens of millions of dollars. Turning south in a few minutes, a massive eight-story, two-square-block, granite-brown building rose to dominate their view. Its central segment, crowned with a Star of David, stood astride the corner of Gracie Allen Drive and George Burns Road. The unusual street names bespoke a subtle reminder of the prodigious financial support given to Cedars-Sinai Medical Center by the tiny city that surrounds it. Walking the corridors to my fifth floor office, Greta and Tyler would discover that every public corridor is a museum of contemporary art, where huge Rauschenbergs compete with Warhol prints.
Greta made a gallant effort to smile brightly as she stood to greet me in my office, but the smile had already vanished before she spoke. As she sat she brushed a nonexistent hair from her forehead, then clasped her hands tightly in her lap. Greta was shouting fear and anxiety without speaking. So instead of talking about her symptoms, I started with family. I talked about my years coaching Little League, and moved on to ocean sports. Her son, Ben, was starting Little League and her husband Tyler was a surfer, she said, with a big smile. Now we were ready to talk about walks along the ocean and jogs in the hills.
I started with her history. Greta didn't smoke, was still menstruating, and had no history of high blood pressure or diabetes. She had never had her blood lipids checked. Her father had died suddenly at age fifty-seven from a heart attack in the past year. Her mother was in good health; she had no siblings.
In diagnosing the cause of chest pain we begin with uncertainty. At one end of the spectrum Greta's pain could be related to a psychological stress, such as her worry over her son. Or perhaps her father's recent death from heart attack had caused her to obsess over her own risk. At the other end of the spectrum, coronary artery disease (CAD) might be the cause of her symptoms. I knew from large databases like the famous Framingham, Massachusetts, study that a thirtysomething-year-old woman with Greta's demographics has less than 1% probability of having CAD. This woman also had chest pain, which increased the probability of disease, but by how much? In cardiology on most days, I find myself standing at the intersection of science and art, where objective probability meets subjective uncertainty.
I asked Greta about her chest pain. Angina, the pain caused by CAD, has three principal characteristics. Greta had all three. Her pain was located behind the sternum, brought on by exercise, and rapidly relieved by rest. The probability of CAD increases with the number of characteristics, and since she had all three, Greta had "typical angina." If we examine all people with typical angina, 90% have coronary disease. For a young woman who begins with a less than 1% probability of disease, typical angina and a positive family history raises her probability of having coronary disease to about 50%.
I reached toward her and said, "Come, I'll examine your heart."
The hospital is elegant; the examining rooms are not. Greta glanced around the tiny six-by-eight-foot room with its spare undecorated white walls, resting her eyes on the narrow, lumpy three-piece examining table, with a step stool at its base. Her anxiety again filled the room as she sat with her legs dangling uncomfortably from the examining table. I started by resting both hands gently on her arm as I palpated her radial pulse. "Laying on of hands" speaks without words. It says I understand your unspoken anxiety. It recalls a parent's touch that says, "I'm here to take care of you." Greta's pulses were all normal. By finding the tap of her heart on her chest wall, I determined that her heart size was normal. Listening with my stethoscope, I heard her heart valves closing normally, with no heart murmur and normal breathing sounds. With a normal heart size, no murmurs, and no evidence of heart failure, I was confident that congenital and valvular was not the cause of her pain and heart muscle disease was unlikely. That left the coronary arteries. Most people with undiagnosed CAD, like Greta, have a normal physical exam. Greta's history and physical exam brought us face-to-face with the ultimate uncertainty, a 50/50 coin flip about CAD. So we would need a test.
Now I had choices. I could recommend either an exercise stress test, or even the definitive test, a coronary angiogram. Because an angiogram is expensive and invasive, I chose a stress test. There is no "right" choice, but this one cost a lot less, and it was immediately available.
The stress test was distinctly abnormal. In her brief visit, Greta's probability of having CAD had skyrocketed from less than 1% to perhaps 90%. For Greta, a nagging unease over a morning cup of coffee was about to ramp up into a pounding anxiety, like a powerful migraine that obliterated every other thought. The diagnosis of CAD with its sinister implications would be a stunning, life-changing, shattering event.
CAD is due to deposits of fat in blood vessels (called plaques or atheromas). Large ones impede the blood flow particularly when the heart needs more oxygen during exercise or emotional stress. Like all muscles deprived of oxygen, the heart sends a pain signal to the brain. When the need for oxygen diminishes, the pain disappears. So, like Greta's chest pain, typical angina is directly behind the chest, precipitated by stress, and disappears within a minute of termination of the stress. Atheromas create two life-threatening risks. They can cause abnormal heart rhythms, including ventricular fibrillation and sudden death. Rapid complete obstruction of a coronary artery by an atheroma causes heart muscle to die (a heart attack or myocardial infarction).
I was taught in medical school that people under thirty-five seldom contemplate their own mortality. Yet this would be Greta's fate this afternoon. How do I tell a thirty-five-year-old mother that she has life-threatening disease that needs immediate attention, when she has never before been sick? I plodded back to talk with Greta, wondering how my sympathy could possibly match her struggle to absorb this personal tragedy. I stopped by the waiting room to ask Tyler to join me. He jumped to his feet with an expectant smile. We locked eyes; his smile vanished as I said simply, "Please join us." As I ushered Tyler in ahead of me, I took a deep breath, and closed the door. I drew my chair from behind my desk to sit beside Greta and Tyler. "Greta," I began, "let me show you what we found." I showed them the ECG. I knew that neither was trained to interpret what they were looking at, but I felt Greta and Tyler needed assurance that specific, objective information provided a foundation for her diagnosis. Allowing Greta to focus on a piece of paper rather than blurting out the dreadful news directly could give her just a little more emotional space and time; a cushion, however small, for her psychic turmoil.
"What's the next step?" she asked after they had seen the test results. My reply was shaped by uncertainty, cardiology's loyal twenty-first-century companion. We had solved the uncertainty of Greta's diagnosis, only to arrive at a new one. In Edgar Allan Poe's famous 1843 Gothic short story "The Tell-Tale Heart," a murderer is flummoxed by the sound of his dismembered victim's heart that he imagines is still beating beneath the floorboards. Was Greta's heart sending me a message of impending doom requiring immediate action, or did we have time to gradually implement treatment? Should Greta have immediate coronary angiography (X-ray pictures of her coronary arteries), or could she first have a trial of pills, say nitroglycerin, which reduces the pain of angina? I recalled nitroglycerin had relieved Willie's symptoms, but it had not prevented his heart attack.
I gave Greta the argument favoring a trial of pills. Her angina was annoying but not disabling in her daily living. She still drove her car, shopped, cooked, and took care of Benjamin without episodes of angina. Her chest pain bothered her only on walk-jogs. She had not yet tried pills to alleviate the pain, but I felt the probability of pain relief with medication was quite high. Furthermore, I knew from randomized trials comparing medical therapy, angioplasty, and bypass surgery in patients with stable angina that, after five years of follow-up, there was no clear difference in survival among the choices. So one option was to initiate intensive medical therapy and closely monitor her response.
(Continues...)
Excerpted from The Heart Healers by James Forrester. Copyright © 2015 James Forrester. Excerpted by permission of St. Martin's Press.
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
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Table of Contents
Contents
Title Page,Copyright Notice,
Dedication,
Author's Note,
PROLOGUE,
PART I: ESCAPE FROM THE DARK AGES,
1. A DAY LIKE ALL DAYS,
2. "WHAT MAN MEANT FOR EVIL, GOD MEANT FOR GOOD",
3. A RIVER OF BLOOD,
4. THE PAIN OF THE PIONEER,
5. A HILL OF BONES,
6. AN IMPOSSIBLE DREAM,
PART II: THE INDUSTRIAL REVOLUTION,
7. ELECTRIFYING DISCOVERIES,
8. THE HEART THAT SKIPPED A BEAT,
9. SINGED WINGS,
10. HOW TO WIN A NOBEL PRIZE,
PART III: THE PAST CREATES THE PRESENT,
11. ONE MAN'S DISASTER IS ANOTHER MAN'S BREAKTHROUGH,
12. WHEN THE PAMPAS CAME TO CLEVELAND,
13. EXPANDING HORIZONS,
14. "THE SHIP HAS WEATHER'D EVERY RACK, THE PRIZE WE SOUGHT IS WON",
15. MERGING STREAMS,
16. THE CLOT BUSTERS,
17. THE BIRTH OF BIOTECHNOLOGY,
18. A BALLOON IN ZÜRICH,
19. CONQUERING ATLANTA,
20. PRICKING ANDREAS'S BALLOON,
PART IV: HOW TO CONQUER CORONARY ARTERY DISEASE,
21. WHY DO ATHEROMAS FORM IN BLOOD VESSELS?,
22. PLAQUE RUPTURE, HEART ATTACK, AND SUDDEN DEATH,
23. A MOLDY GIFT,
24. YOSEMITE,
25. CONQUERING CAD IN OUR LIFETIME,
26. THE PRESENT CREATES THE FUTURE,
27. "ATTENTION MUST BE PAID",
Notes,
Glossary,
Index,
Acknowledgments,
Photos,
About the Author,
Copyright,