The experience of a Life-time
(Part 2)
I recently exposed a chapter of my life on the July 2021 AMHE Newsletter, following minor symptoms of chest discomfort while running to catch an airplane to Ste Croix VI. I claimed my anguishes and I shared my history from reaching the primary care physician in Boynton FL to the cardiologist in West Palm Beach Florida. After a CT of the Coronaries, I rapidly visited my cardiologist-interventionist in Trenton NJ, who directed me toward his lab for different scan, aggressive stress tests as well as a catheterization. I was not a candidate for a stent or any other procedure than an Open-Heart By-pass Surgery.
We reviewed the circumstances which forced me to turn all my interest toward the New-York Presbyterian Hospital where I met Leonard Girardi MD for surgical treatment. A cardiothoracic surgeon is the specialist who penetrates the thoracic cavity and perform procedures to treat conditions of the heart, the mediastinal structures and the lungs and its pleura. Specialists can opt to perform cardiac (Heart and Great vessels) or thoracic surgery (Lungs, Thymus, Esophagus etc).
Most cardiothoracic surgeons follow a rigorous training including years in a general surgery residency as well as in cardiothoracic surgery directing them toward vascular, thoracic or cardiac subspecialities. Some later may subspecialize to attract a pediatric population or now with the age of transplantation, an adult population may also need the expertise of such specialists. Mainly an accomplished cardiothoracic surgeon like Dr Leonard D Girardi would have benefited from an extensive training fo become a Professor of Cardiothoracic Surgery in the Department of Cardiothoracic Surgery department at New York Presbyterian-Weill Cornell Medical Center.
Dr Leonard Girardi is also an Associate Attending Surgeon at the Memorial-Sloan Kettering Cancer Center after completing his undergraduate studies at Harvard University in 1985 and, obtaining a degree in biochemistry. He pursued his medical education at Cornell University Medical College and completed a residency in general surgery at Cornell Medical College, where he remained as a resident in Cardiothoracic Surgery. Dr. Girardi graduated from the program in 1996 under Dr. O. Wayne Isom. After completion of a fellowship in aortic surgery and a six to eight years of intensive training, I was driven naturally to request for his services.
New-York city, this enchanted town, has changed a lot since the COVID-19 pandemic and while on the Riverside driveway heading to the 68th street location, many souvenirs of my previous trips to the town came back to my memory. I was asking to myself, how a hospital was able to be part of many high raise and multi-leveled-building. Beth Israel, Joint diseases, New-York-Presbyterian hospitals etc, all use the same attire to attract their clientele…Indeed, this was my way to divert my thoughts a little, from the tension of the expected visit, and certainly a way to prepare my face to face with Leonard Girardi MD
We valet-parked and were immediately directed to the fourth-floor, North wing for the emergent Cardio-thoracic consultation. Papers filled; Insurance cards shared and rapidly we were introduced to see Laura, a very pleasant and professional physician-assistant. Routine visit, questions answered, a nice moment to prepare us for our interview with her boss. Dr Girardi introduced himself and went directly to the goal of the visit. I was surprised to see the way he had aa absolute knowledge of my situation and the way he knew the details of my pre-operative cardiac procedures: like EKG, stress tests and Cath-lab results, ventriculogram etc. He rapidly confirmed the findings of an advanced coronary arteries disease with complete stenosis of the coronary vessels. He stressed the need to be more aggressive. He was talking about an open-heart procedure to re-distribute the blood to my myocardium. He rapidly concluded that I was a lucky man to have been able to enjoy the beneficial effects of so much collateral vascularization around my cardiac muscle. Perhaps, this has allowed me to remain asymptomatic to-date permitting me to perform the duties of an orthopedic surgeon.
My cardiologist-interventionist was categorical in my inability to rejoin the surgical team at the Governor J Lewis Hospital in Ste Croix VI, to resume my duty. I was forbidden to even think about taking the plane and travel. My new cardiothoracic surgeon would have been more flexible to let me perform a last tour of duty. Just for that, I found a lot of affinity in his decision especially after I was told by my cardiologist that the left stenotic coronary artery was surnamed the “Widow maker” at the joy of Elizabeth who took pleasure to remind it to me. The point was well taken and I called work to cancel my next assignment. I did not have any other choice.
Being a prediabetic on Metformin, and a borderline hypertensive on Lisinopril medication, I may have not been the best candidate for Dr Leonard Girardi but I was better than many others with similar medical problems, he routinely approaches. My case appears to him like a routine and he started describing some details of the operation. He stressed the need to use only one of the internal mammary vessels in the chest, a radial artery in the forearm and the saphenous veins in the legs as needed. He had to be assured that enough tissue was harvested to allow him to perform four (4) coronary by-passes. He routinely uses both internal mammary vessels but with my pre co-morbidities, such approach may jeopardize the healing of the sternotomy wound. He will harvest only one of the mammary vessels because I was pre-diabetic. It would not have been the best recommended choice to take both because of a high 15% rate of wound infection reported in the literature…
The Internal mammary artery (IMA) has been used in pioneered experiences since the middle of last century and become the graft of choice only in the 1980’s after the demonstration of its superiority through widespread angiographic and clinical demonstrations of it superiority over the saphenous vein graft (SVG). Even both mammary arteries have been tried in order to achieve better outcome when compared to an IMA and SVG together. The IMA can be harvested pedicled or skeletonized and used as an in-situ graft or as a Y graft also. The left internal mammary is generally (IMA) is generally hooked to the left descending artery (LAD) and the RIMA attached to the right coronary (RCA) and for the lateral wall it may be anastomosed to the transverse sinus. When a Y graft is used, the left coronary system is preferably chosen as the target site of the re-vascularization. It is often a surgeon experience and I will expose soon what Dr Leonard Girardi chose to perform on me. In anyway, the use of the IMA remains the superior choice especially in younger patients with diabetes or not.
More he was counting on performing part of the anastomosis under an artificial pump while my heart was stopped and the blood by-passed to a machine. Useless to mention that, hearing such, did not arise the best feeling during our tete-a-tete. It looks for me that I would be physically dead for sometimes, in another world, wondering if a return to that body was such a privilege. I have the impression that Dr Girardi felt my anguishes and he was quick to add that especially in a diabetic patient, there were no safer way to proceed. Then, we concluded and left the office with a date for the pre-op tests and a date for the surgical procedure itself. I was impressed by the image of such a man in which hands, I was willing to leave my body knowing well the chances of no-return. I had my fears but I have to say that I kept my emotions well concealed… Fears of the unknown. I kept thinking of my heart not beating anymore and for how long? Heart attack… Paralysis? Strokes… etc… The God of Misericorde will direct the hands of Dr Girardi and will provide him with the best judgement to perform to the best of his ability.
I started reviewing movies of the procedure and approaches performed by the best experts around the world and I watched them closely enough to be able to understand the different steps of such a complicated operation. I also published one of the movies on the AMHE Facebook pages to sensibilize our lecturers. An open-heart procedure performed by a renowned cardiothoracic surgeon.! I waited for comments and reactions on the procedure and read them. Nobody understood my diversion and my will to expose such a delicate procedure, considered as a reconstructive by some or as a salvage procedure by others… in brief, a last chance to a rehabilitation.
After the Cath-lab, I was prescribed Atorvastatin, a statin medication, by the cardiologist to lower my cholesterol and it was the second time I was offered such medication. I rapidly experienced an abnormal reaction to the high dose (80 mg). This time, it was out of the ordinary: I developed muscle pain in the left hip to a point that I was unable to ambulate and bear weight to the left lower extremity with rhabdomyolysis. It was less than a week prior to such an important procedure. More the muscle breakdown affected my kidneys and it became evident that my BUN, Creatinine, Creatine Phosphate, potassium and other parameters were out of the normal values. The physician-assistant Laura was questioning if the specimen of blood taken during the pre-op, was hemolyzed prior to reach the lab. An arterial stick easily performed in the office to confirm the accuracy of the results.
The specimen was not hemolyzed: but a potassium level of 6.3 was a striking finding, wearisome at least, able to stimulate enough cardiac arrythmia. A challenge for the clinicians who encouraged me to increase on the fluid intake in an attempt to regularize and normalize the parameters. The chemical profile was repeated so many times without any conclusive changes. The medical team decided to bring me in 24-hour prior to the procedure and “tune me up”. I was admitted on the 29th of June 2021 to force my diuresis, and impose on me a load of Dextrose 50, controlled by repeated injections of Insulin.
The chemical profile was regularly repeated until the potassium and other parameters were found under control with a normalization of the kidney function. I was finally ready for the operating room. I learned later that I was also exposed to many close members of the family who voluntarily chose not be vaccinated against COVID-19. Hopefully, my COVID-19 test was found negative and my surgery was not postponed. My medical team at the New-York Presbyterian Hospital demonstrated patience and determination. A stretcher arrived exactly at 1.30 PM to pick me up for the operating-room. A dramatic good-bye with Elizabeth and Gerard-Maxime almost bought tears to our eyes.
The operating room was located on the second floor of the building. We went there through elevator, and I walked into the-room to be welcomed by a nurse. I met next, the anesthesiologist in charge to hear that neither of my upper extremities will be used for the taking of the proposed arterial graft (radial) because it was discovered on the duplex pre-op study (I knew it later) that I was doted of a bilateral incomplete palmar arch. The taken of any such radial artery would have jeopardized the vasculature to the hands. The left saphenous vein venous was harvested in a robotic way (endoscopically) with two stab-wound incisions to the left lower extremity, in little time while I felt asleep in Morphea arms. I was induced and smoothly intubated, ready for the surgical procedure. I will extract from the operating report dictated by Dr Leonard Girardi himself the essential steps of the planned procedures:
A Coronary By-pass (anastomosis) X 4 vessels using the middle third of the left Internal mammary artery to the left anterior descending artery (LAD)
A reverse saphenous vein to the first diagonal, the Ramus and the Circumflex vessels
Through a general anesthesia procedure and a smooth intubation, the sternum was prepped and draped and a median sternotomy was performed. The left internal mammary artery was harvested as well as the left saphenous vein endoscopically on the left lower extremity.
Placement on a cardio-pulmonary bypass 2.4L/mm per sq m to maintain a main arterial pressure of 80 mmHg.
Cooling at 32 degrees Celsius while the ascending Aorta is cross-clamped.
Antegrade cold blood potassium cardioplegia to induce a diastolic arrest
Iced slush Cardioplegia each 25 to 30 minutes keeping the temperature near 10 degrees Celsius.
Anastomosis of Circumflex, Right Coronary artery and ramus prior to remove the cross clamps.
Re-warming at 36 degrees Celsius and separation from CP By-pass
Protamine sulfate to reverse the heparin prior to re-establishing ventricular function
This is grossly what my body went through from the artificial arrest of the heart through the cardiopulmonary machine to the Icing and De-icing procedures of my heart followed by the flush with Heparin and the reversal with the Protamine sulfate.
I was in a twilight zone until I woke up without any visible complication and moving all extremities at the satisfaction of my cardiothoracic surgeon. It was 9 30 PM and I came out of an experience which certainly can be compared to an out of body experience. Elizabeth and Gerard-Maxime received the phone call from Dr Leonard Girardi announcing them that everything went well without any complication. And the procedure was performed as planned. It was time for them to go home while I was heading to the Intensive Care Unit.
In fact, I was diagnosed with a progressive angina and marked symptoms on a stress test, marked reduction with an ejection fraction of 71% but a high grade-triple vessel- coronary artery disease and a total occlusion of the circumflex vessels. In spite of all, a normal ventriculogram. I was also selected to be part of a special study in which I authorized the surgical team to enroll me to a study preventing a common complication following such surgical treatment: a post-operative atrial fibrillation which can increase the morbidity on the procedure and rise the hospital cost.
A” Posterior Left Pericardiotomy” was then offered to me. This is a procedure designed by Dr Leonard Girardi and his team used on a routine way following coronary bypasses surgery in prevention of the complication we discussed above. Percutaneously wires were left above the skin, in contact with the left atrium to be used if needed at the end of the procedure, in order to allow some kind of external intervention and hopefully control the cardiac rhythm during a possible atrial fibrillation. Fortunately, I did not suffer from such a complication and 72 hours post-surgery, in the stepdown unit and in the semi-privacy of my room, the wires were easily pulled out.
During our AMHE 2021 convention, a cardiologist-interventionist was discussing a new procedure to control atrial fibrillation and he was demonstrating the way to insert a new gadget in the atrium through a femoral access (groin) and I took the opportunity to ask about his experience with the pericardiotomy surgically performed and practiced almost on a routine basis at the New-York Presbyterian Cornell Medicine. I supposed he understood that I was talking about an all-different procedure used for the same purpose: The Maze or the Cox-Maze procedure also done in the treatment of an atrial fibrillation but completely different from the pericardiotomy performed by Dr Leonard Girardi team. The cardiologist definitely understood that I was asking about the Maze (or Cox-Maze) procedure, a minimally invasive procedure performed under light sedation and while he was pointing the Maze failure rate. I rapidly took the opportunity to send him a copy of the NY-Presbyterian Hospital surgical procedure which was also performed on me recently.
My post-operative period in the Intensive Care Unit appeared to me uncomplicated although Elizabeth and Gerard-Maxime claimed that I gave signs of confusion, especially when they were asking me diverse questions on the chronology of facts to check on my lucidity. It seems that the date of June 10th appeared to be a little repetitive in my answers. This date to which I referred often was a reminder of the Cath-lab experience. Next, maybe, I kept the souvenir of a scary moment when my blood pressure dropped so low that I felt a moment of panic around me. I do not remember it too well but I know that I received an excellent care from the nurses in the Intensive Care Unit. A scary moment….
The 48 hours I passed under their care has allowed me to appreciate even better their dedication to the cause. It looked to me that each patient they cared for and discharged from the unit in good shape, was measured as a victory for their team. I owe them gratitude and recognition for all the “TLC” (Tender Loving Care) I benefited during my admission. They are proud of what they do. They have guided me toward the recovery and I am indulged to the moments I passed being under their care. The Presbyterian Hospital at Cornell Medicine, would never be able to enjoy fame if such dedicated employees were not taking part in a collective goal.
I walked freely with a walker from the ICU to the stepdown unit under cheers from the staff. I reached my new quarter and rapidly found a different configuration. The room was smaller and accommodating two patients. The roommate I met was also a newly admitted with problems related to his cardiac valves. He did not appear to be a surgical case and I overheard a discussion about antibiotics to take during his stay. I needed to get used of the semi-private-room, restricting my independence. I become more aware of my space and my restrictions as well, I lost the comfort I enjoyed while living in the intensive care unit. My legs were dependent and the swelling was interfering with the progresses I have already made during the post-operative period. I did mention it at first but I needed to complaint about the edema to my legs in order to see changes happening. I felt ignored but sensing my discontent, I was assigned a new nurse Karen who quickly discovered somewhere, on the floor, an old recliner able to assist me in raising up the lower extremity especially the one in which the saphenous veins graft was taken.
Leonard Girardi MD
She assured my comfort and my well-being. I want to thank her for making the necessary changes until my discharge from the hospital. Karen was also instrumental in instructing us on the protocol for a smooth discharge. She repeated the directives to Elizabeth while we were heading to the valet-parking lot. This was also on this unit that earlier during the day that the surgical team pulled out the implanted wires communicating to the posterior aspect of the Pericardium, another successful story for the surgical team because they did not have to use the wire to control any cardiac post-operative arrhythmia.
It was time to leave the institution where I was a host for the last four (4) long days. A short wheelchair ride and Elizabeth was already in front of the building with the car. Then I realized that I was equipped with all the post-operative gadget necessary, courtoisie of my daughter Carolyn Lara who carefully chose and sent me all necessary tools for the moment. A special cushion for my sternum with iced pad. Later one, I will discover the content of the Pandora box, very useful during the days of recovery in New Jersey at Elizabeth.
Returning home, I had that envy of a Slurpee Orange-Mangoes and Gerard- Maxime, rapidly googled and found a place near us to cool my thirst. The ride was uneventful and my rehabilitation was on the way. I look forward the enjoyment of losing plenty of weight while being served with a healthier diet. I will need to replenish my depleted Hemoglobin and control more definitively the bad cholesterol which is certainly the culprit in all my cardiac problems. This is in brief, the last page written on the saga of my life. I am looking forward to be under the good care of Laura and Judith both physician-assistants assigned to me and I am sure will guide me toward a complete recovery.
So far, my HgA1C level has passed from a 6.3 level to a 5.4, my blood pressure is normalized to the 110/87 which mean that medication like Lisinopril and Metformin have been eliminated from my armamentarium. I may still remain on Metoprolol medication and Aspirin for the moment until the cardiologist decides differently. Remain the problem which started after the reaction to the Atorvastatin medication for cholesterol, reaction which has persisted with a high level of (K) Potassium to 6.3 for which Kayexalate was prescribed at my last visit to my renal specialist O J-L MD. I am not in acidosis and the parameters for my kidney function are stable in the normal range. My EKG and my heart rhythm are normal. I would enjoy an explanation on the elevation of the serum potassium. Perhaps a plasma potassium level may be needed in the future but until I meet my primary care physician J L MD, in Boynton Beach, FL, I will not know. I am heading to Boca Raton Florida and I remain impatient to discover the date I will beable to return to Ste Croix VI and resume my orthopedic coverage. .I remain also convinced that my efforts to write some pages on this period of my life will not be in vain but will represent a springboard to the one who may be hesitative in front of such an urgent medical situation…
Maxime Coles MD
Boca Raton FL
7-29-21
References:
1. Posterior Left Pericardiotomy for the Prevention of post-operative Atrial fibrillation after Cardiac Surgery (PALACS): Study protocol for a randomized study-controlled trial: Ahmed A. Abouarab, Jeremy R Leonard, Lucas B, Ohmes, Christopher Lau, Lisa Q Rong, Natalia S, Ivascu, Kane O. Pryor, Monica Munjal, Filippo Crea, Massimo Massetti, Tommaso Sanna, Leonard N Girardi and Mario Gaudino.
2. Absolson KB, Nafficy MA (2002): First successful cardiac operation in a human; 1896: a documentation: the life, the, the times and the world of Ludwig Relhn (1849-1930) Rockville MD, Kabel 2002.
3. Johnson SL, (1970), History of Cardiac Surgery:1896-1955. Baltimore, John Hopkins Press. P 5.
4.Newman M, Kirshner J; Phillips-Buke B; Gayer V, et al. (2002). “Longitudinal assessment of neurocognitive function after coronary by-pass surgery”. N Engl J Med 344 (6): pp 395-402.
5. Thoracic Surgery Specialty Description. American Medical Association. Retrieved 28 September 2020.
6. Integrated Thoracic Residency Programs: “TSDA” www tsda.org. Archived from the original on the 31 January 2018.
7. Aris A (1997) Francisco Romero, the first heat surgeon”. Ann Thoracic Surg 64 (3): 870-885.
8. Ariz, Fahad (7 January 2017) “Pleurectomy” Medscape. Archived 6 October 2017.