|Artist of the Heart|
Anyone who handles power tools learns one principle first: they should never be aimed toward the human body. But almost every rule has its exceptions. And on this Monday morning in Rhode Island Hospital’s Operating Room 16, Dr. Richard Hopkins, a professor of surgery and pediatrics at Brown Medical School, has just cut a long incision up the chest of a man named Roland Barnes, slicing through the skin to the bone. He peers down at the gash through special bifocals, and then, without hesitation, he drives an electric saw directly down the patient’s sternum, cutting it cleanly in half. Next, Hopkins attaches a device called a retractor snugly over the bone on each side of the sternum. Turning a wrenchlike device, he ratchets the gap in the patient’s chest slowly wider, drawing the two halves of the sternum apart like curtains in a theater.
The stage is the heart, and the opening act is about to begin.
The chief of cardiothoracic surgery at Providence’s Rhode Island Hospital, Hopkins is a round-faced, perpetually genial man with bushy eyebrows, a down-to-earth manner, and an encyclopedic knowledge of cardiac surgery. A cut-glass bowl on a mahogany table in his office is filled with mechanical heart valves and a human pulmonary valve preserved in fluid and sealed in a plastic bag. On one of the slate-blue walls hangs a framed drawing from his book, Cardiac Reconstructions with Allograft Valves. The bookshelves are filled with volumes with titles such as Heart Disease in Infancy and Childhood and Textbook of Surgery. Hopkins has written nearly 150 journal articles on cardiac surgery and has set up the Collis Cardiac Surgical Research Lab at the hospital to develop heart valves that can be colonized with the recipient’s own cells, allowing them to grow and heal like natural human valves.
He currently performs about 175 surgeries every year, a third on children. In and out of the operating room he is frank and clear. “I would make a very poor politician,” he admits. Over the years he has performed so many operations that he can easily identify the subtleties that distinguish an excellent surgery from a merely good one. “You have to be a good surgeon as a craftsman,” he says. “Just as an artist has different mediums, acrylic or oil, we have different tools. But then there’s what I call the art of surgery. People in the operating room can tell when a cardiac surgeon has accomplished the craft of surgery, but they might not be able to tell if I’ve accomplished the art of surgery. That’s the zen of surgery. The outcome for the patient is subtle but real.” An artificial valve may last longer, for instance, or there may be fewer postsurgical complications, or the patient’s long-term health may be slightly better.
Hopkins likes to compare his role to that of a general during battle. He claims that most of the crucial nontechnical aspects of surgery can be found in Sun Tzu’s The Art of War, written around 500 B.C. Sun Tzu is mandatory reading for Hopkins’s surgical residents. He also required his three kids to read it. In surgery, as in battle, he says, “you have to know what your strategic goals are and what your tactical capabilities are—and then you have to win the war. You have to know what you have to know and what you don’t.” War, Sun Tzu wrote, “is a matter of life and death, a road to either safety or ruin.”
But the old axiom is true: heart disease can be a silent killer, and without open-heart surgery, Roland Barnes would die. His decline would take place gradually, over months, even years. But he would die, certainly and painfully, of congestive heart failure as his aortic valve slowly hardened into solid deposited calcium. He suffers from a condition called aortic stenosis, caused in Barnes’s case by a congenital defect in his aortic valve. In a normal heart, as blood exits to deliver oxygen to the cells of the body, the aortic valve has three leaflets that spring open and snap shut as the heart beats. But, as is the case in 5 percent of the population, Barnes’s aortic valve has only two leaflets. The resulting turbulence wears down the valve faster and increases calcium buildup on the leaflets, which become so thick and hardened they can’t open properly. Eventually, the heart is unable to circulate blood properly throughout the body, and the lungs slowly fill with fluid. In the end, the pump fails and the person dies.
During the past month, Barnes has endured a battery of evaluations: EKGs, echocardiograms, pulmonary function tests, X-rays, stress tests, urinalysis, blood work, even a dentist’s appointment to make sure he has no abscesses that could lead to infection. He has quit smoking. “I’m very nervous,” he said before the operation. He knows that after surgery he will be in the hospital five or six days and will be in recovery for several more weeks. He knows there is a slim chance he will not come out of the operating room alive.
Today is the day that the aortic valve of Roland Barnes will be replaced by the aortic valve of a pig.
“Needle, please,” Hopkins says to the scrub nurse. “And wire, please.” The scrub nurse stands at the foot of the operating table beside another table covered in turquoise sheets and holding such sterile tools as electric cautery pens, forceps, a variety of clamps, barbed needles, several syringes, scissors, and knives: the heart surgeon’s tools. Also in Operating Room 16 are three cardiac specialty nurses, a perfusionist (who will soon be running the heart-lung machine), anesthesthesiologist Bert, and two cardiothoracic surgeons who are assisting Hopkins. They work together frequently; they know their roles and can anticipate their interactions. Each new surgery is a variation on a well-rehearsed play.
Hopkins inserts a hollow-tipped needle into the right femoral artery running along the inside of Barnes’s groin. Hopkins’s movements are confident and smooth: hesitation has no place in the operating room. A wire slides easily through the needle and into the artery.
“It’s a beautiful thing,” he says. “It’s a beautiful thing.”
He pushes a tube the size of an index finger over the wire and into the artery, releasing a miniature geyser of vermilion, oxygenated blood, which momentarily pulses into the air. The tube, which is blocked off not far from the point of insertion, fills almost instantly. Hopkins hooks a plastic hose into the end of the tube. “It’s a beautiful thing,” he says.
The tube, or cannula, is one of several that will divert Barnes’s blood away from his heart in a procedure called cardiopulmonary bypass. Hopkins now turns his attention to the heart, where he needs to place a second cannula. It must be inserted into the right atrium so it can carry away the blood arriving at the heart from the rest of the body. To put in this cannula without triggering massive bleeding, Hopkins uses purse-string sutures, a circle of stitches that can be tightened by pulling the ends. He sews quickly—the movements of surgery are partly training, partly experience, and partly instinct, and he has all three. After the sutures are in place, he nicks the large vein in the middle of the suture ring and puts his finger over the hole. He then quickly punches the plastic cannula through the cut and pulls the sutures tight.
Surgery, Hopkins likes to say, must go straight from the eyes to the fingers. Surgeons must have extensive medical knowledge, but they also need the ability to grasp concepts in three dimensions and to translate this instinctually into the movement of their hands. During his residency, Hopkins knew a colleague who would take extensive notes on every surgery he observed. But when Hopkins tried this approach, he says, “I lost all the subtleties translating it into linear language.” Even now, although he may not remember the names of patients he operated on years ago, he can often recall precisely what their hearts looked like, a thousand or more operations later.
“Want to go on?” asks Jeff Gough, the perfusionist, from his position near the heart-lung machine.
“I’d love to go on,” Hopkins replies.
Gough turns on the machine and allows it to gradually take over Barnes’s circulation. It is 9:05 a.m. Hopkins seals the aorta shut with a cross-clamp. For most of the operation, the only blood flowing through Barnes’s heart will be through two spaghetti-thin cannulas that Hopkins will insert into the coronary arteries to supply just enough blood to nourish the heart tissue.
Next a high-potassium drug, called cardioplegia, which stops the heart from pumping, is injected into Barnes’s bloodstream, causing the steady lub-dub, lub-dub contractions of the heart to cease. A dose of cardioplegia will be injected every fifteen to twenty minutes for the rest of the surgery. Barnes’s heart keeps quivering a little, as if trying to muster enough rebellious energy to pump. But it remains mostly still, a slightly bloodied, defeated hunk of muscle amid an awkward-looking array of tubes and pumps that have taken over its elegantly simple work. On three screens around the OR, the EKG line goes flat. Heart rate: 0.
As the cannulas direct Barnes’s blood into the heart-lung machine, a blood thinner called heparin, administered intravenously, keeps it from clotting. Another medication has stopped Barnes from breathing on his own. Dark, purplish venous blood flows into a bag reservoir and then through a centrifuge pump. From there, the oxygen-depleted blood moves to an oxygenator chamber. A heat exchanger maintains the temperature of the blood, which is then pumped through a filter and into the cannula in the femoral artery. Cherry red with oxygen, it is finally returned to Barnes’s circulatory system.
“Turn on the CO2,” Hopkins says. The air in the chest cavity is replaced by carbon dioxide, which is rapidly diffusible and reduces the risk of fatal bubbles forming in the blood. Hopkins then takes a metal pitcher filled with icy saline slush and, as though filling a cooler, dumps it into Barnes’s chest cavity to cool and protect the heart.
Successfully putting a patient on the heart-lung machine is the opening act of open-heart surgery. Now act two can begin.
“Doctor,” Hopkins asks Dr. George Cooper, one of the assisting surgeons, “do you want to take the pulmonary artery?”
As Cooper grabs it with forceps, Hopkins starts snipping deftly through the aorta. There is a constant parlay of commands and confirmations between him and the scrub nurse. “It’s a little like being the conductor of an orchestra” is how Hopkins describes his work as a surgeon. “You know the job of everybody, and you have to keep them synchronized.”
Hopkins pulls the flesh aside and peers down the tunnel of the aortic root to the aortic valve, surveying the terrain and the enemy. He wears a video camera on his head and a strong light attached to his surgeon’s glasses. What he is looking at is displayed on a television screen above the operating table. When Barnes’s faulty valve appears on the screen, its leaflets are clearly laden with calcium.
“Scissors?” Hopkins asks.
He inserts the scissors into the chest cavity and withdraws them a moment later, pulling out a chunk of flesh. “There’s the valve,” he says matter-of-factly.
Barnes’s aortic valve is passed around the operating room in a small paper cup. Most of the tissue is slippery and pliable, but the valve itself feels like a tiny, irregular piece of coral.
Hopkins continues to remove bits of the valve. “We almost got all the calcium out,” he says, asking for sterile tools one after another. “We’re going to take out the whole aortic root,” he decides after examining it. The risk of a ruptured aneurysm is just too great. More slush goes into the chest. Cooper grasps the aortic root with forceps and Hopkins cuts slowly down its length. The two coronary arteries, which supply the heart tissue with blood, are attached to the section of the aorta that Hopkins will be removing. The dissection of the coronaries from the aorta is the most technically challenging part of this surgery; there is very little room for error. “He wins his battles by making no mistakes,” wrote Sun Tzu. “Making no mistakes is what establishes the certainty of victory, for it means conquering an enemy that is already defeated.”
Hopkins makes no mistakes. He carefully slices around each coronary artery, leaving a button of flesh around the end of each to sew onto the replacement aortic root. He operates in a tiny box of blood-filled tubes, slush, and flesh, among a palette of reds and pinks. He couldn’t be happier.
When Hopkins was thirteen, he and his family moved from St. Louis to Durham, North Carolina, where his father took a job as a vice president at Duke University. (The following year in England, Donald Ross performed the first transplant of a human heart valve.) As a teenager, Hopkins gravitated toward part-time employment that centered around hospitals or medical research. His first job, when he was thirteen, was as a paperboy at Duke Hospital, where he sold 100 newspapers each morning for ten cents apiece. As a surgeon years later he would work with some of the nurses he’d met on his route.
Hopkins earned his bachelor’s degree in chemistry from Duke in 1970, working as a scrub nurse to help pay his way. He saw his first cardiac surgery, a valve operation, as an undergraduate. Hopkins graduated from Duke School of Medicine in 1974. For the next ten years, he trained at Duke Medical Center to become a cardiothoracic surgeon. He finished his training with a yearlong stint in the cardiothoracic unit of the Hospital for Sick Children in London, where he observed his first homograft transplant of a valve from a cadaver to a human. The surgery deeply impressed him. Using human tissue instead of the mechanical valves then more commonly employed in the United States struck Hopkins as a brilliant idea. He brought the technique back with him.
Hopkins taught and continued to operate at Washington University in St. Louis and then at Georgetown. While at Georgetown, he performed about 500 cardiac surgeries annually. Then in 1996, Brown recruited him, and Hopkins and his wife and two children moved to Providence. The two oldest are now at Duke, but the youngest is still home in Providence, and despite Hopkins’s busy work schedule, he finds time to coach her fast-pitch softball team.
In addition to his work as a teacher and surgeon at Brown Medical School, Hopkins continues his research on tissue-engineered human heart valves, which he believes would be particularly helpful to children. An important problem for children with artificial heart valves is that they outgrow their valves and must have several heart surgeries to replace them. He estimates that tissue-engineered valves are three to five years away from human trials.
“I have the best job in the world,” says Hopkins. “I get to be an artist, I get to be a scientist, I get to be a doctor all at the same time.” If Leonardo da Vinci had to choose a profession today, he adds, it would be reconstructive cardiac surgery.
Hopkins excises the pig coronaries, leaving two round holes in the aortic root. He lowers the valve into Barnes’s chest cavity and, using a needle shaped like a fish hook, begins to sew, pushing and pulling the needle through the Dacron ring on the valve and then through Barnes’s heart tissue.
Hopkins concentrates as he sews, but the act is not a mental one so much as it is a motion of habit patterned into his steady fingers. Some people can ride bikes, some can whistle; Hopkins can sew on an aortic root and make the action look natural and routine. He jokes with his fellow surgeons as he sews. His humor is a surgeon’s humor, consisting of wisecracks about a pulmonary valve.
Hopkins stitches in a small lagoon of blood, sewing away for fifteen minutes, thirty minutes, forty minutes. He occasionally mutters triumphant exclamations: “Oh yeah, that is so sweet.” “We should have a slam dunker.” Or his favorite: “It’s a beautiful thing.” Gradually, the pig’s aortic root becomes a tubular extension of Barnes’ heart, and by 10:30 a.m. it is firmly attached by a neat ring of blue sutures, with the patient’s coronary arteries in place.
Hopkins clips a little patch of pericardium, the sac surrounding the heart, to sew onto a slight gap between part of the right coronary artery and the aorta. Sweating, he asks the nurse to pull off his glasses and headlamp and then starts sewing again. The patch is done in ten minutes.
Hopkins next asks for a tube of white Dacron to replace the floppy and weak aortic tissue above where he originally severed the aorta. This tube will connect the pig tissue to the healthier part of Barnes’s aorta.
“Horrible tissue, horrible tissue,” he says.
After finishing, he turns to Gough. “Fill up the heart, please,” he says.
“Transfusing,” Gough replies.
The heart inflates with blood. Where before there was a largely flat mass in Barnes’s chest, there is now a round muscle that looks like a red potato. Bert, the cardiac anesthesiologist, turns on the respirator, and its bellows begin pumping rhythmically. The heart is pushed up and down in the chest cavity as the lungs inflate and deflate, a sea of blood rising and falling along with it. Hopkins sews two little blue wires into Barnes’s chest. He will slip them out in a day or two, but until then they will allow doctors to attach an external pacemaker as needed.
Barnes is off the heart-lung machine at 11:04 a.m. His heart beats tentatively and irregularly at first. The waveforms on the EKG monitor form a jagged mountain range with no two peaks the same. As the beating becomes more vigorous, the electrical activity approaches a normal pattern. By 11:15 the screens show a heart rate of eighty-eight beats per minute with the even, symmetrical waves of a normal heartbeat.
“It’s a beautiful thing,” Hopkins says.
And it is a beautiful thing.
“I’m not a terribly religious person,” he says later, “but every time you deal with the limits of life and death and the beauty and complexity of the human body, the more you sense the presence of a greater meaning.”
Hopkins and another surgeon sop up the blood in Barnes’s chest cavity with sterile cloths. They go through one, two, four cloths while a nurse suctions more out with a tonsil-tip catheter. The bleeding is more than usual.
Hopkins removes the venous cannula and sutures the hole closed, then moves on to the arterial one.
“It’s a beautiful thing,” he says again.
And the team closes up Roland Barnes’s chest.
“Is his sister—?” he asks the nurse standing nearby.
“She just left.”
“Of course.” Hopkins stares intently at Barnes’s vital signs on the screen. The nurse brings in another bag of blood to replace what the patient is losing. It is 3 p.m. Hopkins climbs down onto his hands and knees, removes his glasses, and studies the blood entering the PleurEvac unit beside the bed. He marks the level with his pen.
Barnes’s legs twitch slightly. “Roland, Roland, your operation is over,” the nurse says. “You’re in the intensive care unit.” He doesn’t respond, but it’s the first time he’s shown signs of consciousness since the surgery.
At 3:15, Hopkins decides to wait fifteen minutes longer. He sits down in front of the PleurEvac and stares at it with a fixed, pensive gaze. The blood continues to drain into it. Whenever something doesn’t go as planned in a surgery, Hopkins has two responses. The first is the clinical, directed toward solving the problem or analyzing what occurred. The second response is more emotional. If a baby or a child dies, Hopkins’s family knows to leave him alone for a few hours when he returns home. Still, he emphasizes, tragedies cannot be avoided entirely. A surgeon must learn not to take things too personally.
Hopkins calls Bert, who arrives at 3:30. Hopkins marks the PleurEvac with his pen again at the 1950 cc mark. It rapidly fills to 2000.
He turns to Bert and says, “We’re going down.”
“I’m starting, Arthur,” Hopkins says at 4 p.m.
“I’m all set, chief,” Bert replies.
And with that, Barnes’s chest is opened for the second time that day. The suction tubes slurp.
Hopkins stares at the open chest. A single needle-prick hole in the Dacron tube is squirting blood. “This,” he announces, placing his finger on it, “is the proverbial finger in the dike.” He sews on a tiny patch of Teflon felt.
“That’s all it was,” he says, a little incredulously. “Dry as toast.” He puts a single piece of gauze in the chest and it does not even soak through.
At 4:20, he draws the two sides of the sternum back together. The curtain closes.
“Bye, everybody. Glad we got done before five,” says Hopkins, as another surgeon and the nurse wire together and suture the chest again.
And with that, the general heads out until the next battle.
Lindsay Ryan is a development studies concentrator from Washington, D.C.