It was 3.45am when Dr Stephen Westaby got the call. He was urgently needed at the John Radcliffe Hospital. A baby girl desperately needed heart surgery and it could not wait. It was the middle of the night. Dr Westaby had enjoyed a good dinner, and with the help of a generous quantity of Merlot and several melatonin tablets had been enjoying a deep sleep. But that was not the main problem. The dying baby was in Oxford. He was in Sydney.
He jumped on a plane that morning. He rang the hospital from Singapore to learn more about the baby whose name was Kirsty. He spent the rest of the flight planning the operation. In her short life Kirsty had already suffered multiple heart attacks. Her heart was scarred and feeble. As soon as he arrived in Oxford Dr Westaby explained his intentions to the surgical team and then set about opening Kirsty’s chest. When Dr Westaby exposed the heart he had a shock.
Instead of being the size of a walnut, it was inflamed to the size of a lemon. But he carried on, placing Kirsty on a heart-lung machine while he replumbed the arteries. All went well until he tried to take Kirsty off the machine and allow her heart to take over again. Although it was now receiving a good supply of oxygenated blood the heart would barely beat. It was simply too large.
After several attempts to restart the heart Dr Westaby could do no more. He went to break the bad news to Kirsty’s parents. Confronted by their misery he spun on his heel, strode back into the operating theatre and determined to try something he had heard about but never attempted. He cut out a section of the heart and sewed up the hole. The lemon had now shrunk to become a walnut. Again he tried to wean Kirsty off the heart-lung machine. This time it worked.
I was at the Blenheim Literary Festival last weekend when the now Professor Stephen Westaby recounted this story. Then like a conjuror he produced a final flourish. ‘Kirsty is here today,’ he declared and summoned on to the stage a pretty girl, who has enjoyed eighteen years of robust health since being rescued from death’s door.
If you want to understand why somebody becomes a heart surgeon you should read Westaby’s book ‘Fragile Lives.’ A working class boy from Scunthorpe who saw his grandfather collapse and die from heart failure, Westaby was driven by a desire to help heart victims. A workaholic, he performed 600 heart operations each year – four times the typical workload of today’s surgeons. In his book he describes several instances in which, racing against time and reacting to successive crises, he pulls patients back from the brink of death – and sometimes cannot. You can feel the adrenaline rush.
Like brain surgeon Henry Marsh, whose book ‘Do No Harm’ is another great read Westaby has no time for health service administrators tightly clutching the purse strings nor today’s risk avoidance culture. He was an innovator. Early in his career he invented the ‘Westaby Tube’, a Y-shaped stent that restores the functioning of the major airways. Then in 2000 when Peter Houghton, having reconciled himself to death, presented himself at the hospital Westaby had no hesitation in trying something that had never been done before. He fitted Houghton with an artificial heart, powered by a battery linked via a wire that entered through his skull. Houghton lived for seven years during which time he wrote a book of his own (‘On Death, Dying and Not Dying’).
The , named after its inventor Robert Jarvik, is not really a replacement heart at all. It is basically a pump that fits inside one of the chambers of the heart and takes over its pumping function. Although not approved in the UK except in extremis, Jarvik hearts are regularly fitted in the USA and the experience has demonstrated three things. First that the heart does not need a pulse. Mechanical pumps drive blood around the body at a constant pace and this seems to be just as effective as a pulsed delivery. Next the Jarvik can keep the patient going until a donor heart becomes available – a so-called ‘bridge to transplant’. But more exciting and unexpected was the ‘bridge to recovery’. The fitting of mechanical hearts has demonstrated that natural hearts can, if given a break, recover. So some patients have had the Jarvik fitted and then removed when their natural heart is back to normal.
Doctors such as Stephen Westaby, and other pioneers whom I mentioned in Issue #278, understand that it is only by pushing the boundaries that we advance our knowledge. Which takes me back to Kirsty, and an extract from the book:‘When we felt she was old enough to discuss it we asked for permission to carry out a scan to show how the remodelled heart had developed. What we found was quite extraordinary. Apart from the double-orifice mitral valve (created by Westaby’s operation) her heart appeared normal, as did her new left coronary artery. Only a thin scar showed the position of the line of stitches up the heart. Remarkably, all other scar tissue had disappeared. The whole inner lining of her left ventricle had been pure white scar tissue – now all gone.’
This revelation demonstrated that an infant’s own cardiac stem cells can regenerate heart muscle. ‘Adults cannot recover in the same way,‘continues Westaby, ‘unless we can identify and culture stem cells for an adult heart, inject them at the same time as their coronary bypass surgery or get them in through a catheter in the heart.’ Westaby has taken up this challenge and is assisting Celixir, a company set up by Sir Martin Evans and based in Cardiff. Last year Celixir reported the results of a trial in which allogeneic stem cells were delivered during bypass surgery to eleven patients suffering from severe heart failure. The result was a 30% improvement in heart function, a 40% decrease in cardiac scarring and after 36 months all patients remained alive. The treatment, called Heartcel has now been licensed to Daiichi Sankyo in Japan, leaving Celixir to plan trials in the USA and Europe.
Meanwhile another private company based in Wales and backed by Westaby, Calon Cardio, is preparing to test a new and improved mechanical pump. Called the MiniVad this is designed to overcome problems experienced by some patients with pumps, namely damage to the blood and dangerous clotting.
Medical science is indeed fascinating, it is rewarding for doctors and for patients – and, by exercising due care and attention, it is rewarding for investors also.