You are humbled and at the same time overwhelmed by the trust placed in you by another human being.
It was the moment of reckoning for us. The day we had been preparing, for over a year had arrived. We were about to do our first replacement of the aortic heart valve, through an artery in the leg, a procedure called 'Transcatheter Aortic Valve Replacement', also called TAVR. The team assembled for the pre procedure briefing. There were a total of 14 people on the team, with five doctors, across four specialties. We went through the case, an 85-year-old man, Robert Smith, who had already undergone bypass surgery, which was complicated by healing issues 10 years ago.
I had first met Mr Smith two months ago and we hit it off immediately. He was not doing well, and we knew that the problem was with the valve in his heart. He did not want to undergo another open-heart procedure. We went through the new procedure, and he asked me the obligatory question, “How many had our team done”? While we had done multiple procedures in training in Germany, he was going to be the first patient in our hospital. “None,” I answered. “You are going to be our first patient”. There was an awkward silence. “I understand your concerns,” I broke in. “I will be happy to refer you to a more experienced centre,” I added.
The nearest centre doing the same procedure was an hour and a half away in a different city. He thought about it for a minute, looked me in the eye, and said, “ I want you to do it.” It was one of those emotional moments. You are humbled and at the same time overwhelmed by the trust placed in you by another human being.
The team had been together for the past six months. Everybody had a very specific role. We went through the case, and played out all the possible case scenarios for the umpteenth time, especially the scary ones. We had a plan for virtually any eventuality.
The procedure is relatively straightforward and ingenious. First, described by a French doctor, Prof Alain Cribier at the university of Rouen in 2002, it involves putting the new valve over a balloon-mounted stent, into the diseased valve. A valve in the heart as a concept is something like one way swinging doors, that are watertight when they close. The new valve is initially collapsible, and once expanded, pushes the old valve leaflets (doors) out of the way, and the new leaflets, begin regulating blood flow. The new valve is similar to the tissue valves currently available that are replaced by standard open surgery. The procedure is relatively new, with Medicare, approving the first generation valve and procedure in the middle of 2012, and the newer generation that is currently used, being FDA approved in 2014.
The procedure is still restricted to higher volume centres, who must commit to strict adherence to protocol. All patients are tracked carefully in a national registry. If there is a higher mortality than expected, the programme will be under review. The consensus document also calls for the interventional cardiologists and cardiothoracic surgeons to do the procedure jointly, necessitate the “heart team” approach, a collaboration between specialties.
A final checklist and timeout was done, and the procedure got underway. The initial steps went like clockwork. My surgical colleague exposed the artery in the thigh, we got across the diseased valve and positioned the new valve without any issues. To deploy the new valve, we have to stop the heart from pumping, which we achieve by making the heart go very fast, by stimulating it with a pacemaker at rapid rates. It is during this 20 second interval, that the valve is deployed, with virtually no room for error. The longest 20 seconds of our lives came and went, and we were able to nail the valve to where we wanted to be. The heart came right back to function, when we stopped pacing and my heart, which to me, had stopped too, came back to life. We confirmed deployment on the screen and on ultrasound. It was time to close up and head to the post procedure debriefing.
After reviewing the case, we began preparing for our second case of the day. Mr Smith was up and out of bed that evening. We chatted a bit and discussed what doctors do. Unlike most other professions, doctors cannot have a bad day, without significant consequences. You don’t get any do-overs. Mr Smith slept well that night, as did the rest of the team.