congenital heart disease

So I had seen allthat these people did, and Bill wrote for the gastrointestinal surgery and so on, andbreakthroughs. And it was very clear to me that this was a breakthrough moment. Veryimportant breakthrough moment in the history of surgery, that the heart could be finallyattacked. Now, the interesting thing, by the way, all of the efforts originally for openheart surgery were for congenital heart disease. No acquired heart disease. So it was all childreninitially. All children. Or adults with congenital heart disease. Now, the other thing that Ilearned there, of course– I was a resident– since there are only two institutions whodid it in the world, who did this heart surgery. So they came from all over the world. I sawthat many came too late, you see.

They had pulmonary vascular obstructive disease. AndJesse Edwards was in pathology and developed an understanding of the effect of pulmonaryhypertension on the evolution of pulmonary vascular obstructive disease and so on. Soit became very clear to me from relatively early that that corrective operation had tobe done early. Because if that persisted, that cause secondary damage to the heart andthe lungs. Now at that time, what was early in your mind? Well, early, first I thoughtbefore going to school. That was my first thing. But then slowly, we came down to theconclusion, no, that’s too late. And then we started once I was on the staff, I hada lab.

Once we were on the staff, we already had a lab. We had to have a lab. We had toget money from the NIH over there to do some research. So I had a lab. And there, one ofthe experiments we did was important was we put two kilogram puppies to see if they toleratedcardiopulmonary bypass. We did a lot of experiments. And came to the conclusion that they did verywell. We looked at blood. We looked at the lungs. We looked at the heart and so on, andthe central nervous system. To dissect out how they would respond to cardiopulmonarybypass at that early age. I mean, they’re two kilogram puppies. And we developed someinstruments for infant cardiac surgery also, and stuff. So that work, we started alreadyin Minnesota to do earlier kinds.

But when we really made the breakthrough through wasthe neonate, first months of life, was here at Children’s where we did the first arterialswitch operation in neonates. It was a 10-day-old child. And we did a complete correction withthe so-called arterial switch operation. And that opened the movement of congenital cardiacsurgery towards the neonate. What year was that, the first switch? ’83. ’83. I mean,we did experimental work from ’60. The paper, the first paper, probably was about ’66 inMinnesota still. I came to Boston in ’72, to Children’s. And we did the first neonate,clinical neonate, in ’82. January 2nd, ’82. So Dr.

Castaneda, can I ask you this. Youjust clearly described that your research was going in that direction. And so I’m interestedto know was it your accumulated belief from the observations that you’d had that theycame too late, these patients came to Minnesota too late. And that really what was drivingthe movement to repair newborns was based on your observation.

And candidly, everythingelse had to fall into place. The anesthesia, the bypass, the pre and post operative care.Correct. Or was it that technology was simultaneously evolving that made better pre-operative diagnosis,better post operative care. I’m interested in which is the lead point. I mean, I don’ttry to imply that I’m the only one that did that. The Japanese had been interested inoperating, and they developed a technique of deep hypothermic circulatory arrests at20 degrees centigrade.

We used it at the beginning, but at the end, we thought it was not– wedid some studies. In particular, an associate of mine, Dr. Jonas, Richard Jonas, now inWashington. That circulatory arrest, even at 20 degrees centigrade, if you really studiedthose children post-op well, they had some neurologic deficit. And we switched againback to cardiopulmonary bypass. That switch operation at the neonatal level, that firstkid was 10 days old. That was a breakthrough. Now, of course, in a well established unitin the first world, the distribution is about 60% are neonates. Imagine this, It’s a tremendousamount. And about 30% are within the first year, and only 10% are beyond the first year.

While in the third world, like in Guatemala, for example, we have about 5% in the neonate,because the diagnosis are not being made early enough in outlying countryside and so on.So we have a long way to go, but in a good units around the world, that’s what they’lldo. So the neonatal surgery is here to stay. There’s no question about it. What were thechallenges as it evolved? I mean, I imagine there were challenges in making sure thatthe pre-operative diagnosis was correct, that the operative technique was correct and thebest it could be.

But along that chain of care, what were the particular challengesof moving the repair ever earlier in life? Well, you know, well enough to be very clear.And by the way, I even found it out more so when I went to Guatemala than when I was here.The surgery is not the big hero of this whole thing. That’s nonsense. This cardiac stuff,it requires a team. And it is like a chain. And everything works OK if all the parts ofthe chain are OK. If one fails, the whole thing fails. What I mean by that is if surgeonis no good, no good either. Yeah, but not only no good. Anesthesia, heart-lung bypassteam, post-operative management. I mean, we all dependent on one another.

So I think thatpeople– I mean, visitors came a lot to Children’s and all that. One thing I think we did herepretty well was that we had created an environment and everybody was recognized as equal. Itwasn’t the big surgeon because he did the surgery. You can do the best surgery. If thepump fails, anesthesia is lousy, and the post-op management is lousy, the results are not verygood. That it obvious. So we create– and particular with nursing, you know. That wasinteresting.

I always felt that the nurses were extremely well educated, very capable,but were underused in general. I mean, what they were allowed to do. And the nurses wantedto do more. But the hierarchy, they had the chief nurse of the hospital, was very reluctant.It was interesting. To let them think more independently and act independently? I thoughtthey are intensive care unit. When we got the residents every year, we had new residents.First thing I told them, I said, listen. You might be thinking you are very smart, Harvardgraduates and all that kind of stuff. The nurses know more than most doctors. They staywith the patient there at the bed side in the intensive care unit. They know the patientbetter than we do. We waltz in, waltz out, which is almost true. And I had much respectfor the nurses.

And I think they noticed that. And we created an environment in which everybodywas equal. Could I turn now and ask you some questions about what it was like for you tobe a pediatric heart surgeon? And some of the things I’m wondering are what was it liketalking to parents over time? Because when you started, the mortality rate was higher.And yet the parents were, in the earlier part of your career, likely more deferential perhaps.But did talking to parents change? Did it become more– That’s an interesting subject.Some people do it well and some people don’t by nature. I don’t know exactly why.