“A Phenomenal Surgeon”
In past years, the pediatric heart program at Inova Fairfax had been considered solid, but it rose to a new level with Shen’s 2006 arrival. Karr calls him “a phenomenal surgeon.”
Trained to operate on the most complex congenital heart defects, Shen has broadened the scope and depth of the Inova pediatric cardiac program. He formed a partnership with fellow cardiac surgeon Lucas Collazo, who has been at Inova since 1999 and is in his mid-forties.
“Irving has just the right balance of ego, security, and humility and is a delight to work with, and so is Lucas Collazo,” says pediatric cardiologist Thomas Hougen, a professor of pediatrics at Georgetown University who refers many heart patients to Inova Fairfax. “They make a very good team. The medical students I send over there are always surprised that two top-flight surgeons are so easy to get along with. Their experience at other places is not like that.”
Dr. Hougen says training alone doesn’t create a great surgeon. “It’s a combination of things. Some surgeons have it—and I’ve seen others train for years and never attain it.”
The mutual support between Drs. Shen and Collazo is important because the attitudes of the surgeons determine how well the support staff—nurses, technicians, and the perfusionists who operate the heart-lung bypass machine—perform their jobs. In virtually every conversation I have with them, the two surgeons credit the entire cardiac team for any success they’ve had.
Although Inova Fairfax isn’t as well known as the country’s premier pediatric heart programs at Children’s Hospital of Philadelphia and Children’s Hospital Boston, results for the more than 300 young patients who annually undergo heart surgery in Inova’s pediatric-surgery program are published every year and rival those anywhere.
As Shen navigates the miniature landscape of Taylor’s chest cavity, he’s aided by physician assistant Tom Lauer. Shen exposes Taylor’s plum-colored, pulsating heart. With surgical scissors, he delicately cuts open her pericardium, the thin, translucent sac encasing her heart. She has been given heparin, an anticoagulant, to prevent clotting. He then inserts plastic cannulas into her vena cava and aorta, the body’s two largest vessels, which connect Taylor to the heart-lung bypass machine. He loops sutures to tighten the seal and hold the cannulas in place.
The perfusionist circulates Taylor’s blood through a cooling coil in the heart-lung machine, a process that drops her body temperature to 27 degrees Celsius (about 80 Fahrenheit) to slow her metabolism and reduce the demand for oxygen in her tissues, especially during the time Taylor’s heart is stopped and the heart-lung machine—“the pump”—circulates her blood. Unlike the heart, which pulses blood when it beats, the pump streams blood continuously.
Shen clamps the aorta to stop the blood flow and signals the perfusionist to inject potassium into an IV line inserted directly into Taylor’s heart. The tiny organ, throbbing only moments earlier, is stilled in less than half a minute as the potassium shuts down its electric circuitry. The EKG monitor flatlines, and her abruptly stilled heart becomes flaccid as the heart-lung bypass machine takes over, eliminating the major fear—that her heart will suddenly fail.
Shen cuts into the fibrous heart muscle itself and suctions blood from inside the heart chambers to gain better access to the atrium. Karr watches on an overhead monitor as Shen incises a precise opening in the back of the atrium before undertaking the meticulous task of maneuvering into place the four unconnected pulmonary veins, all conjoined into one, and suturing them to the atrium with a series of intricate stitches. Throughout the procedure, Foley periodically reports that Taylor’s vital signs are stable.
At about 5 am, with the connection complete and Taylor’s heart sewn back together, the room’s temperature is raised to 65 and Taylor’s blood is warmed by the heart-lung machine’s heat exchanger. As the surgery team watches, Taylor’s heart stirs to life as they wean her off bypass. For the 164 minutes that Taylor was on bypass, her heart was effectively dead. Its beating seems almost like a resurrection.
Karr performs a post-op echocardiogram while Taylor is on the operating table. The infant’s right heart, once dilated and abnormal, now appears nearly normal. Her left ventricle is small, unused to the copious amount of blood it now has to pump. It will take a few days for it to adjust. Karr is elated to observe normal blood flow through the pulmonary veins and into the left atrium—a perfect connection.
Relieved of the stress of monitoring Taylor through more than four hours of surgery, Foley is thrilled by the surgery’s success.
Because swelling can occur postoperatively, Shen doesn’t close Taylor’s chest immediately, leaving the heart room to expand.
Before sunrise, he meets with Joe in the pediatric ICU, where Taylor lies sleeping in a small bed, still on the ventilator amid a nest of tubes and lines. Bandages cover her open chest while behind her head a wall of monitors flickers and beeps.
Shen tells Joe that the surgery went well, Taylor’s heart is repaired, and her condition is critical but stable.
“Will she need any more surgery?” Joe asks.
“I feel confident she will not need any more surgery,” Shen replies.
Joe thanks him repeatedly.
Shen smiles. “It’s my job,” he says.
Joe looks into Shen’s eyes and thinks: The man is physically exhausted.
He calls Amanda and his parents to give them the news.
Later that morning, Amanda is discharged from Reston Hospital Center. Her sister picks her up and drives her to Inova Fairfax. Amanda remains at Taylor’s side day and night, refusing to leave the hospital until her daughter can.
Three days after surgery, Collazo closes Taylor’s chest. Every day Taylor’s heart grows stronger, and every day Amanda thanks the surgeons as they come by on their rounds.
“They Die in India”
In a softly lit conference room, physicians, nurses, and cardiac technicians gather for a weekly “cath conference” every Wednesday at 5 pm. Here they go over the most troublesome pediatric heart cases—children suffering from devastating congenital heart defects or who have undergone unsuccessful operations at other centers. Dressed in blue scrubs, Shen and Collazo attend along with cardiologists, nurses, and other staff.
“We hold these meetings to go over these difficult cases and try to reach consensus on how to proceed,” says Shen, who chairs them. “We don’t need to discuss the cases where the answers are clear-cut. We also strive to keep our meetings collegial and constructive. They’re not ABC, like at some other institutions.” ABC, he explains, stands for “accuse, blame, and criticize.” Even good hospital cardiac programs can be damaged by finger-pointing in such meetings, Shen says.
For each case, the child’s condition and history of medical interventions is presented by the patient’s cardiologist. All the participating doctors, while affiliated with Inova Fairfax, are in private practice—and in many cases in competition with one another. While this has the potential for turning the meetings into ego clashes, Shen and Collazo make sure it doesn’t.
“The purpose of the cath conference is primarily educational,” Collazo says “because we learn from each other. This is particularly important now that we are taking on many more complex cardiac cases. It’s all about patient outcomes—it’s not for people to get their egos stroked.”
The two dozen or so doctors in attendance see images from three-dimensional echocardiography, CT and MRI scans, and x-ray fluoroscopy on the large screen in the front of the room. To the untrained eye, the images might as well be a Google map of New Jersey, but to trained eyes the grainy images reveal crucial information.
The image of a beating heart appears on the screen. Fine-mesh stents that opened a severely narrowed vessel are visible, as is the rivulet of blood flowing through them. It’s the heart of a young child born with multiple defects who, despite several interventions and numerous medications, still struggles for breath just walking across the street. One cardiologist notes that children with these types of complex heart defects aren’t even operated on in some countries. “They die in India,” he says.
Even though the treatments and medications the child is taking are palliative, the doctors concur that in his weakened condition the risks of additional surgery are too high.
“We’re not talking about getting this child to age 70,” one cardiologist says. “We’re trying to figure out how to get this child to 17.”
They decide that the best course is to wait and see if the child’s condition improves enough to tolerate surgery. “I think we should wait until we have no choice but to intervene,” one doctor says, and there’s general agreement among the others. Perhaps the child’s only hope will be a heart transplant.
Another case flashes on the screen, which shows a dark, circular area in a child’s chest. I ask the cardiologist next to me what it is.
“It’s a pacemaker,” he says. “They used to be the size of hockey pucks, but they are much smaller and much better now, like comparing an old A-frame to a modern computer.”
The physicians discuss other complex cases as well as a death, and as they do I think back to the summer of 1961 at Peter Bent Brigham Hospital, now part of Brigham and Women’s Hospital in Boston, when I came to know two men who were also undergoing heart surgery.
One of them, a genial fellow who expressed little fear, strolled the corridors in his maroon robe, and we often talked in the doorway of his room. We wished each other luck. I still remember the shock I felt when I was told he’d died on the operating table.
Soon after my own operation, I learned that the second man had died a few days after his surgery to repair a defect similar to mine. He was about 35, and I knew that if the technology that saved my life hadn’t been available until I reached 35 or so, I might have suffered the same fate. I suspect that their cases were discussed at Peter Bent Brigham in the same way as the cases being discussed in the conference I witness at Inova Fairfax.
There were no sophisticated cardiac-imaging technologies such as three-dimensional MRIs, CT scans, and echocardiography in 1961—stethoscopes, electrocardiograms, and x-rays were the only diagnostic tools available. Also lacking was the wealth of accumulated experience and knowledge doctors could draw on to better understand the human heart. The survival rate for heart surgery in those days was 60 to 70 percent at the leading institutions.
Today, 95 percent of babies born with congenital heart defects can expect to reach adulthood, and survival rates in pediatric heart surgery at centers such as Inova Fairfax are at or near 100 percent for many defects, making losses today seem that much harder to accept.>> Next: The Delicate Art of Intervention