Sunday, May 27, 2012

New Members of the Scientific Advisory Board

The Bicuspid Aortic Foundation is pleased to announce two new members of our Scientific Advisory Board:
Jason Sperling, MD, FACS, Subspeciality Director of the Thoracic Aneurysm and Bicuspid Aortic Valve Program at Valley Heart in Ridgewood, New Jersey, and Cheryl Maslen, PhD,  Professor of Cardiovascular Medicine and Molecular and Medical Genetics in the Oregon Health Sciences University School of Medicine, and Associate Director of the Heart Research Center there.

We would like to thank each of them for their work in these areas so vital to those with BAV and other forms of thoracic aortic disease. We are deeply grateful for their desire to voluntarily assist the Foundation in fulfilling its charitable mission.

Saturday, May 19, 2012

Find It and Fix It First!

In the ER
Crushing chest pain sent him to the nearest emergency room. His blood tests and EKG were normal - no sign of a heart attack. Maybe it was a bad case of GERD? They gave him a common antacid and admitted him for observation.

In the Hospital Room
The next day, arrangements were made to send him by ambulance to a hospital run by his HMO. They were just waiting for the ambulance to come.

If you were in the hospital that day, you might have wondered who was in trouble as Code Blue echoed through the hallways and waiting rooms.

It was this man, thought to have a problem with his digestion. His heart had stopped.

The nurse that got there and began CPR was strong, the chest compression forceful. His heart began to beat again.

In the Cath Lab
How had they missed this last night? Surely, he must have a blockage somewhere in the arteries in his heart. He was rushed to the "cath lab", where a catheter was threaded from an artery in his groin up into his heart. Squirting dye into his coronaries showed beautiful, clear, healthy blood vessels. No blockage there.

Then the cardiologist squirted dye into the aorta. And there it was, a tear in the ascending aorta.

And then, his heart stopped again.

If you were in the hospital then, you might have heard this over the loudspeaker: "Code Blue, Cath Lab!  Code Blue, Cath Lab!" And you might have wondered whose life was in danger.

They worked desperately on him, trying to get his heart to beat. At the same time, emergency calls went out for heart surgeons.

Somehow, his heart began to beat again.

When Every Millisecond Counts
It was the end of the day. One heart surgeon was in his office. Another, already headed home, was stuck in traffic.

There was a rush to assemble a team for the operating room. A thoracic surgeon will pitch in to help until the second heart surgeon can get there. They have to move this man from the cath lab to the operating room - will his heart keep beating?

His heart has already stopped twice. Everyone knows now that he is bleeding inside. His heart must keep beating. But every time it beats, he may be tearing and bleeding more.

Where is all that blood going? How long can he hold on?

Yes, they know he is bleeding and his aorta is torn. But rather than clear pictures from a CT scan for surgeons to look at, they have only the angiogram images. There is no time for more tests now. Not just every second, but every millisecond counts.

There is very little hope in this picture. Someone must explain to the family that the survival statistics are grim.

In the OR
On the table in the OR now, his heart still beating, the surgical team began their work.

For the third time, his heart stops.

They had given heparin, but he was not yet on the heart lung machine. This must be one strong heart, as somehow they help it beat again. This was the third "code".

Soon, the heart lung machine had taken over, circulating his blood. His heart does not beat,  but it is all right this time. The surgeon has begun to address the catastrophe inside his chest.

Any who may have been praying continued to pray.

The Outcome
It is too painful to wait longer to find out what happened to him.

He came though surgery beautifully. There was no brain damage. He went home in three days!

He is counted now among those amazing survivors who, against all odds, are still with us. Aortic dissection survivors and their families, like John and Tina Becerra,  may describe miracles and angels that helped save their lives. Surgeons such as Dr. Mark Poole who performed emergency surgery on a young mother   mention the limitations of human capability under these extreme conditions.

What Helped This Man Survive?
As they worked on him, some things became more clear about what had been happening inside.

A Tear in his "Heart Sack"
There was a lot of blood in his chest cavity. It appears to have leaked out from the sack that surrounds the heart, called the pericardium. When his heart stopped the first time, it was likely because the aorta ruptured open and blood flowed out and into this sack around the heart. When this happens, the blood compresses the heart and it cannot beat. This is called pericardial tamponade and is quite often the reason for sudden death during aortic dissection.

 But why did his heart start beating again? They found a tear in that pericardial sack around his heart, and blood flowed out through that tear into his chest. As the sack emptied of blood, the pressure around his heart lessened, and it could beat again. Remember the strong nurse that pushed so hard on his chest in his hospital room? It is likely those forceful compressions on a pericardial sack full of blood caused it to tear. It was one of the things that saved him.

Sealed by a Blood Clot
But how long could he live if he kept bleeding like that - from the aorta into the heart sack, from the heart sack out into his chest? What happened is that a blood clot formed over the ruptured spot in the aorta, sealing it and keeping his blood inside the artery.

In the OR, when they gave heparin, it likely dissolved the blood clot, and blood began to escape outside the aorta again. His heart stopped for the third time then.

His life was hanging by the thinnest of threads. Many things helped him survive in the midst of this disastrous aortic emergency:
  • He was not sent home from the hospital.
  • The ambulance did not come for him early.
  • A strong nurse pushed hard enough when doing CPR to break open the pericardial sack.
  • A blood clot formed over the rupture site in the aorta and stopped more blood from leaking out.
  • He was stable while moving from the cath lab to the OR.
  • A skilled aortic surgeon was nearby when calls for surgeons went out.
  • The surgical team restarted his heart from that last cardiac arrest and got him safely on the heart lung machine.
Why Not Find It Sooner? Let's Think of the Aorta in the Chest!
Why didn't someone think about this man's aorta? Why wasn't a CT scan ordered in the ER once a heart attack was ruled out? Aortic dissection is one of the three deadly causes of chest pain.

We know now that many hours went by before his heart stopped that first time. There was also a history of sudden death in his family. There was time to check his aorta. It was not done.

The medical literature indicates that there is a need to first of all think about the aorta. This paper from Germany mentions a campaign to help medical professionals think about aortic dissection in critical situations. This paper from Japan talks about the three conditions to rule out (including aortic dissection) when dealing with patients with chest pain, before turning to less immediately deadly causes.

We All Can Help Think of the Aorta
Greater awareness by individuals and families can help save lives. How? By learning about the aorta and any conditions that affect it, knowing and telling medical professionals about any sudden deaths of blood relatives, and reminding physicians and other medical professionals about the aorta.

Talking about the aorta before there are any symptoms may result in the earliest possible discovery. And if there are chest symptoms, it is vitally important to think of the aorta.

 If you have symptoms in your chest
 and are told by doctors it is not your heart,
 ask them to check your aorta.

Find It and Fix It First!
What does finding it first mean? Finding it as early as possible, before it has an opportunity to injure. If it has already injured, finding it before it has an opportunity to kill. When dealing with the aorta in the chest, early detection may save lives.

Searching online for "aortic dissection law firm", one law firm's website has a detailed description of aortic dissection and the risk factors associated with it. When physicians and medical professionals think of the aorta, particularly along with the other reasons for deadly chest pain, the aorta can be ruled in or out. When physicians do not think of the aorta,  lawyers seeking damages may follow.

This is a path that no one wants to travel. 
Let's find it and fix it first!

It all begins with thinking 
about the aorta,
Creating a Climate of Hope.