Solving the Mysteries of Heart Disease

by Gerald D Buckberg

  But this was only the beginning.

  The life of a researcher is much like that of an explorer. Yet most successful researchers achieve one significant finding, and it predominantly defines their career. This holds true even for Nobel Laureates, who (with the exception of just four) have all been honored with a single award for their extraordinary work.

  I ended up pursuing ten different major research goals. I appreciate that this approach may seem scattered. Yet it more aptly represents the difference between an explorer who searches out one island… vs. someone whose broad vision sees that there are many islands before them, each needing exploration. For me, the yardstick is always the research’s quality, not its quantity. Therefore, my team and I focused on a single project over a three to six year period. There were no detours into other research until we completed each full endeavor.

  In addition to losing my dear grandfather to a heart attack, I later watched my father suffer the devastation of congestive heart failure. I wanted to help people, but I also wanted answers. Thus, I entered this world of cardiovascular research to solve unresolved problems. The number of patients that this could affect would vastly exceed those I could help by individual treatment in my operating room. I embarked on a voyage of discovery that has raised new questions — and resulted in my finding answers that contradict many commonly accepted medical beliefs.

  The breadth of our research covered questions such as:

  Must congestive heart failure incapacitate and ultimately kill the patient, or can the heart’s health be restored?

  Must “sudden death syndrome” (cardiac arrest — when the heart stops and CPR is applied) end up killing 90% of its victims, and leave its rare survivor with brain damage, or can this be avoided?

  Must part of a patient’s heart muscle die after an acute heart attack and create a weakened heart in many who survive?

  Must a successful replacement of a diseased heart valve sometimes turn into a fatal event because the heart’s inner lining dies?

  Must some babies (called “blue babies” due to deficient oxygen in their blood from a heart defect) suffer permanent heart and brain damage after an otherwise successful surgical correction of their congenital problem?

  Must the large muscle in the middle of the heart (the septum) become almost routinely damaged during many successful heart surgeries?

  Must modern pacemakers continue to create the same abnormal heartbeat contractions that were first reported as long ago as 1925?

  How does the true structure of the heart (largely unacknowledged in medicine) determine its function and lead to new findings that will save countless lives?

  The pages that follow describe the exciting chase that led to solutions to every one of these compelling questions — plus others.

  In each case, the starting point for our research was a problem we saw in the patients. A game plan evolved where we’d begin by seeking a deeper understanding of why something happened… then correcting it experimentally… and then finally using this new knowledge for the successful treatment of patients. Once this was done, I could establish guidelines for others to reproduce these treatments. Only then did we move onto the next challenging investigation.

  This path into uncharted territory meant we could not to be put off by failure. Rather, each defeat brought with it fresh questions that would lead us onto the next step. Also essential was my willingness to advocate solutions that would contradict conventional thinking — an approach that must be coupled with an unbending drive to continue forward, even if our answers are not initially accepted. The ultimate reward is to come to a complete understanding of a problem’s underlying cause, and its successful medical solution. Solutions that can be used by others.

  Each story of discovery will be told in just one or two chapters. But each task represented a daunting puzzle at the time. Addressing them needed inventive approaches. My hero, Albert Einstein, famously stated, “Imagination is more important than knowledge.”

  Creativity always played a vital role in my life, starting when I was young and interested in art. This interest in the crossover between science and art remains strong, and five chapters toward the end of this book talk about how I merged the two to develop new outlets to communicate my work. Importantly, those chapters also discuss how a creative mindset enables one to find answers to difficult problems.

  Despite these exhilarating breakthroughs in treating cardiac problems… unexpected difficulties have tempered the joy of our successes. The welcoming reception our blood cardioplegia work received was never repeated. Instead, each new life-saving discovery was met with rigorous resistance.

  We found solutions to major heart disorders afflicting millions of people… but no one is listening.

  I had unknowingly encountered a parallel for this dilemma early on, while applying for medical school. When asked to name my favorite book, my answer was The Cry and the Covenant, about Ignaz Philipp Semmelweis, a Hungarian physician in the 1800s who realized the frequent occurrence of childbed fever in the maternity ward was due to infections caused by the delivering doctors. This was before the emergence of the germ theory. The titans of medicine shunned Semmelweis because he asked them to wash their hands.

  As I would learn firsthand, resistance to dramatic new ideas that can reverse awful illnesses has not lessened. Though the positive results of our studies were confirmed in patients, first by myself and then by other leading physicians around the globe, they were disregarded by those who determine the “medical standard of leading care.” Yes, ours reflected “radical changes” from how treatments are currently done, but they were even “more radical” in another pivotal way: their success rates were remarkably higher than the outcomes with traditional methods.

  While this has certainly been frustrating, it has never deterred me from searching for the next answer. I know that the truth will win. These innovative approaches will eventually be adopted because they work.

  The question is, how long must that take?

  I am pleased to share our quest, which spans over 50 years of research and heart surgery practice. It’s a story of formidable twists and turns, met by a readiness to think outside the box, and energized by an unrelenting thirst for discovery. This memoir is written to breach the medical barricades I have encountered. I’m writing directly to the general public to let you know that answers to major cardiac illnesses exist now, but are not currently used.

  It is your turn to discover what has been learned. Please read on and join me on my voyage.

  Gerald D. Buckberg M.D., D. Sc.

  Distinguished Professor of Surgery

  David Geffen School of Medicine at UCLA

  Department of Cardiothoracic Surgery

  TABLE OF CONTENTS

  Foreword by James L. Cox

  Introduction: Exploring Uncharted Territories

  CHAPTER 1 Truth Will Win… But When

  CHAPTER 2 A Series of Fortunate Events, Encounters, and Lessons

  CHAPTER 3 A Compelling New Path

  CHAPTER 4 Becoming an Investigator

  CHAPTER 5 Great Expectations

  CHAPTER 6 Discovery: Myocardial Protection and Blood Cardioplegia

  CHAPTER 7 Improvement: Cardioplegia Saves Lives

  CHAPTER 8 You Don’t Have to Die of a Heart Attack

  CHAPTER 9 Restoring Life to a “Dead” Heart

  CHAPTER 10 Reoxygenation Injury: If a Little Oxygen Is Good, Is a Lot Better?

  CHAPTER 11 Back from the Dead: Sudden Death and the Lazarus Syndrome

  CHAPTER 12 Unwitnessed Arrest Part I: The Never Taken Pathway

  CHAPTER 13 Unwitnessed Arrest Part II: Expansion, Rejection, and Future Realities

  CHAPTER 14 The Teacher’s Highest Reward

  CHAPTER 15 Unanticipated Interlude

  CHAPTER 16 Congestive Heart Failure: Education to Enactment

  CHAPTER 17 Congestive Heart Failure: Enactment

  CHAPTER 18 Paco: Exploring the New Horizon
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br />   CHAPTER 19 Art and Science: Nature’s Grand Design

  CHAPTER 20 The Helix and Heart Failure: The Dilated Heart, Footballs, and Basketballs

  CHAPTER 21 Art and Science: The Helix and Heart Video

  CHAPTER 22 Diastolic Dysfunction: Contracting Longer but Not Better

  CHAPTER 23 Art and Science: The Cardiac Dance; Spirals of Life

  CHAPTER 24 The Case of the Missing Link: The Septum

  CHAPTER 25 Art and Science: Stonehenge and the Heart

  CHAPTER 26 The Helix and Cardiac Disease: The Riddle of Pacemakers

  CHAPTER 27 Life: My Art and My Science

  EPILOGUE: My Journey

  Resources/Overview

  Reference List

  Image Credits

  Index

  About the Author

  There will be a number of opportunities for readers to view videos that illustrate some of the research findings discussed throughout the book.

  To view any video, type the address link shown below each video into the search bar of your web browser.

  eBook readers can click directly on the link beneath each video.

  CHAPTER 1

  Truth Will Win… But When?

  “I think you need to take this call.”

  Twenty years ago, my administrative assistant stood in my office doorway. Normally, she wouldn’t be so insistent unless it was one of my patients or one of my interns with a pressing question. It wasn’t either of those.

  “So who is it and what’s it about?” I asked.

  “Some doctor in Birmingham, Alabama. He didn’t take time to explain, other than to say it was urgent. You need to take the call.”

  I picked up the phone. “This is Dr. Buckberg. Who is….”

  He didn’t let me finish. “It’s Connie Athanasuleas. We met at the Duke conference. I drove you to the airport.”

  I remembered him. Well-respected cardiac surgeon, bright, articulate, assured. His tone now, however, seemed to make clear he wasn’t looking for a thank you or merely to renew acquaintances.

  “Tell me what’s going on.”

  Connie explained that he had just completed a coronary artery bypass graft to improve blood flow to the heart of a 65-year-old woman. It was a routine operation. Since the 1980s, the survival rate has been around 98%. Of course, for a patient, nothing is routine about open-heart surgery, and complications can still occur.

  “Everything went as expected,” he confirmed. “But then I was in the visitor’s room and speaking with the patient’s family when my pager went off. I rushed back to the ICU.”

  His patient was having ventricular fibrillation — where the heart’s electrical activity becomes disordered and the main pumping chambers contract in a rapid, unsynchronized way. This causes the heart to quiver, rendering it incapable of pumping blood. It is a lethal event, requiring cardiopulmonary resuscitation (CPR), which provides external compression that can squeeze the heart, allowing it to keep a patient alive by circulating blood to the body.

  By the time Connie arrived, his ICU staff was administering CPR and applying a defibrillator to try shocking the heart back into a normal rhythm. All to no avail. His patient was dying. She was becoming part of the 2% death rate.

  The standard belief at the time was that after 15 minutes of unsuccessful resuscitation, the heart and brain sustain irreparable damage and any attempts to revive the patient should stop. Even before those 15 minutes are up, there is only a 10% survival rate, and half of those few survivors will suffer severe brain damage. For Connie and his patient, time was running out.

  That’s when he called me.

  Just two weeks earlier, I’d met Connie for the first time at Duke University, where I was giving a series of talks on coronary artery surgery. One of my talks described a new approach to treating sudden death (cardiac arrest, where the heart suddenly stops) that my team at UCLA had recently developed and used successfully on patients in our hospital.

  My lecture revealed our early findings for 14 patients with whom we had administered CPR for an average of 55 minutes before they were put on a heart-lung machine (which takes over circulation and oxygenation of blood throughout the body) — which then allowed us to surgically repair the underlying problem causing sudden death. We even had one patient to whom we successfully administered CPR for 150 minutes!

  This was unheard of at the time.

  Our approach, employing groundbreaking treatments following a greatly extended use of CPR, had never been done before. As I mentioned, conventional wisdom was that CPR lasting longer than 15 minutes always resulted in 100% mortality. Yet we found 11 of our 14 patients had complete heart and brain recovery — nearly an 80% survival rate.

  While my presentation at Duke was well-received, you never really know what will come from these talks. Oftentimes ideas are exchanged, but then are quickly forgotten as everyone returns home to their comforting practice of “business as usual.”

  Connie hadn’t forgotten.

  Calling from his ICU, Connie quickly filled me in on his patient’s status. The situation was uncannily similar to what I had discussed during my Duke lecture. I wasted no time and went over the exact procedure he’d need to follow. It was important we act fast.

  “First, you need to ensure that whoever is performing CPR is told to press hard enough on the chest to maintain adequate blood pressure — greater than 60 mm Hg — to make sure sufficient blood is reaching the brain.” (Most CPR only provides about one-third the amount of blood needed by organs.)

  “Next, proceed immediately to the operating room. Put the patient back on the heart-lung machine, as you will need to operate on her again. You need to decompress the heart with a vent tube to ensure it is empty. Then make certain each bypass artery you put in is open, since a blocked or closed artery could cause the unexpected fibrillation.”

  Connie was in new territory now, as we had already passed the supposedly always-lethal 15-minute limit of CPR.

  “Connie, proceed immediately with this. Now, let me talk to your perfusionist.”

  Mike Rose, the perfusionist (who runs the heart-lung machine), got on the phone. Fortunately, Mike had visited me a year earlier at UCLA to learn about our methods for protecting the heart during cardiac surgery, so I knew he was up to speed on our methods. I told him to administer a “cardioplegic solution” to the patient for 20 minutes. This solution is a mixture of the patient’s blood that is modified by adding specific substances (using an ingredient composition I designed) that protected the heart.

  “After Connie decompresses the heart and checks the newly implanted arteries, you deliver this solution. Then supply regular blood to the heart for 30 more minutes.”

  I hung up as the clock was ticking. It was in their hands now.

  Less than an hour later, Connie called with an update.

  It was great news.

  He confirmed the implanted coronary vessels were indeed open. As soon as they had completed delivering the special cardioplegic solution and begun normal blood flow, the heart’s activity returned so vigorously that his patient was easily taken off the heart-lung machine. In fact, no supportive drugs were needed to improve the heart’s ability to properly contract. He said the entire surgical team was amazed. So was Connie. He was grateful, too.

  Four days later, Connie called back to report that the patient had been discharged and had suffered no brain damage. Connie said it was like a miracle.

  Of course, it wasn’t a miracle. It was just good science.

  This was validation for me on several levels. First, we had saved a life, which is why we do this. Second, Connie was the first person outside of my team to perform this new technique for treating sudden death, and he learned about it at a seminar.

  Finally, and this is the case with all of my research after being proven true, I could envision the immense impact this groundbreaking approach would have as word spread and more and more doctors like Connie adopted this new technique.

  Thi
nk about it.

  We had changed the belief that more than 15 minutes of CPR meant certain heart and brain death, 100% of the time. Now it had been proven that the heart and brain could last through as much as 150 minutes of CPR, with nearly 80% survival!

  This would change the way CPR is taught in the classroom and how emergency responders would treat sudden death when picking up and transporting the patient to the hospital. Emergency rooms would soon be equipped with heart-lung machines and more technicians would be trained for their relatively easy hook-up. Surgeons would have more time to treat and correct the underlying conditions that caused the sudden death in the first place.

  Hundreds of thousands of lives would be saved every year around the world! Victims of heart attack, drowning, suffocation, seizure, drug overdose, electrocution — all the things that cause the heart to suddenly stop — these people could have a second chance to live.

  This was not a small advance, but a revolutionary shift in the way we think about and treat sudden death. Our study, conducted at one of the world’s leading institutions in cardiac research, led by recognized investigators in the field, with its techniques successfully proven in patients — had yielded an entirely new approach to treating a condition that strikes without warning and causes devastating results in half a million people yearly. It was nothing less than stunning.

  For me and everyone involved, it was cause for rejoicing. And it was the first step in another of a series of significant steps to transforming cardiac care.

  20 Years Later: Where are We Now?

  Today’s standard protocol for dealing with sudden death states: after 15 minutes of unsuccessful resuscitation, the brain and heart sustain irreparable damage and all attempts to revive should cease.