Advances in Care

Heartmaker: Revolutionizing Pediatric Heart Surgery

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Heartmaker: Revolutionizing Pediatric Heart Surgery
Heartmaker: Revolutionizing Pediatric Heart Surgery

Dr. Bacha, Chief of the Division of Cardiac, Thoracic, and Vascular Surgery at NewYork-Presbyterian/Columbia, tells the story of how he successfully implanted a Total Artificial Heart into one of the youngest patients in the world to undergo the surgery.

Emile A. Bacha, MD
Emile A. Bacha, MD

Dr. Emile Bacha is a board-certified cardiothoracic surgeon with a subspecialization in pediatric cardiac surgery.

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 BACHA: The first operation I saw… I was like, oh my God, I was blown away. 

MUSIC

It was an operation called an arterial switch operation, which is an iconic operation, very famous operation done in babies and newborns who are a few days old. Tiny. Tiny. And it's a very elegant operation. I was newly married at the time, uh, my wife, uh, talks about today when I came back. She said I was glowing. I was like, I fell in love with somebody. 

CATHERINE: When Dr. Emile Bacha returned home from work that magical day – after witnessing his first heart surgery on a tiny infant – he knew. He knew that he was going to become a pediatric cardiac surgeon.

BACHA: …and I, uh, I've never regretted that decision.

THEME BEGINS

CATHERINE: I’m Catherine Price and this is Advances in Care – a podcast from NewYork-Presbyterian hospital – where we talk about the cutting edge research, the pioneering treatments and the complex cases behind some of the biggest advancements in medicine. 

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Today, Dr. Emile Bacha talks about the latest innovation in pediatric heart surgery: the total artificial heart.  

THEME PLAYS OUT

CATHERINE:  It’s been twenty-five years since Dr. Bacha made the decision to become a pediatric cardiac surgeon. Today, he’s Chief of the Division of Cardiac, Thoracic, and Vascular Surgery at NewYork-Presbyterian/Columbia. And he has performed approximately 8,000 heart surgeries on children and infants.

MUSIC TRANSITION

BACHA: The heart is the most commonly affected organ with congenital defects. Nearly 1% of all babies are born with some type of congenital heart defect, which is – if you think about it, 1% doesn't sound like a lot, but 1% of all newborns is a lot of babies. Pediatric heart surgery... Obviously it's not for the faint-hearted. I, you know, uh, I don't know. I think… you have to be

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able to stay calm and to stay calm, especially when things are not going right. That's a key ingredient to being successful. So it's a lot like an athlete, if you will. When you step onto the field, you have to be able to summon yourself to perform whatever task it is. If you're gonna be spending a sleepless night, and you're gonna be the next day completely, you know, jittering and, and, and shaking well that's not good. So you have to be able to keep your nerves under control. For some reason, you know, I was born that way, I think. 

CATHERINE: Dr. Bacha was born in Lebanon. And way before he was operating on tiny hearts, he was a quote, ‘middle-of-the-road’ student. (Those are his words, not mine.) He says all the best and brightest of his peers ended up going on to be engineers. But not him. His path, in a sense, ended up having less to do with his science class grades, and more to do with his disposition – his ability to remain calm, to summon focus.

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And maybe, even more than that, it had to do with his grandfather.

BACHA: I wanted to be a physician because my grandfather was a physician. I was close to him. so he influenced me. I ended up going to medical school, then really loved surgery, uh, with a big “S”. 

I think what it was is uh the immediate effect you have on people. When you are in, in non-surgical specialties: medicine, psychiatry, neurology, it's a much slower pace because you are getting to know the patient, then you decide you're gonna try this treatment, that treatment, medication, pills, you know, psychotherapy, whatever it is. And the changes occur typically fairly slowly over time. But I tend to be impatient, a little bit, in terms of what results I want to get. And so what was appealing to me is the immediate gratification and result you get. If, if you're a heart surgeon and you're a pediatric heart surgeon, you close the hole, 

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you can go out, tell the parents, ‘That’s it! Your child is fixed. Your baby can go out to have a normal life. After this, you don't need any medication, recover from surgery, and you're done.’ And that's, uh, that's a nice, beautiful, very effective way to, to treat, uh, disease.

MUSIC

CATHERINE: So here’s a brief refresher on the evolution of heart surgery: Shunts were introduced in the 1940s – which was a huge innovation. But the first big paradigm shift was the introduction of the heart-lung machine in the 50s. Suddenly, it was possible to do open heart surgery. But survival rates were only about fifty percent. And of the patients who did survive, many didn’t recover their brain function. So – in the past decades, doctors have been focused on figuring out ways to minimize risks, and maximize post-op quality of life.

BACHA: The surgery has become much safer. We now really protect the brain extremely well. It's not only survival, but it's a quality of life that's crucial. I can now look

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the parents in the eyes and say, we're taking your patient to surgery, but I can, I can be 99 plus percent sure that your child is going to be, come out of there and be able to do whatever they want to do, cognitively speaking and physically speaking. 

CATHERINE: But, ultimately… No matter how much you improve the process, it still doesn’t solve the problem of supply: there just aren’t enough transplantable hearts to keep pace with demand.

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BACHA: You have to typically wait a month and sometimes years until you get an organ available. And the younger and the smaller you are, the longer you wait. So when we have babies who sometimes need heart transplantation, come to us and, and we need a heart transplant, we know we're gonna be waiting six, nine months, twelve months, sometimes. It's very tough because, uh, sometimes they do, they don't survive that, that time period because they're typically in an ICU and sick. So therefore you need sort of mechanical assist devices, something that can assist the, the heart 

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while you're waiting for a transplant. 

CATHERINE: And that brings us to the second big paradigm shift.

BACHA: The majority of the assist devices are what's called ventricular assist devices, whereby you do not remove somebody's heart. Instead, it's like adding an extra pump to the pump you already have. So it's like you have your own heart and you have a derivation of blood into an an external pump. And that external pump can be sometimes in the chest, but it's laying next to your own heart. You have not removed the patient's own heart.

CATHERINE: But – there are rare cases when leaving that patient’s heart inside of their chest is precisely what kills them. And that brings us to what could be considered the third paradigm shift: the invention of the total artificial heart. A one hundred percent mechanical heart.

BACHA: The total artificial heart has been sort of something people have been pursuing for a long time. It's very different from other assist devices. Total artificial heart is when you take out somebody's heart

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entirely, Take it out. And replace it with a artificial heart inside the patient's chest. 

CATHERINE: So the idea of a total artificial heart actually goes way back to 1937, believe it or not.

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CATHERINE: One Dr. Vladimir Demikhov was experimenting with implanting his artificial heart invention into dogs. And surprisingly, the surgeries were semi-successful. The animals would survive for about a month post-op—which is actually really quite impressive, given that this was before the advent of the heart-lung machine. Apparently, Dr. Demikhov would just operate really really fast and had quote, ‘his own methods’ for preserving organs while he worked. Over the next several decades, experiments and engineering evolved until the first human patient was successfully implanted with a total artificial heart on December 2, 1982. The patient, sixty-two year old Dr. Barney Clark, lived for 112 days after the surgery. The 

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total artificial heart that’s used today was developed by Syncardia. And it’s usually referred to as the TAH. In the last 35 years, it has helped bridge thousands of adult patients until a new heart is available for transplant. But until recently, this type of mechanical support was still relatively new for pediatric patients. 

BACHA: The premier indication for the TAH is having a chronically rejecting patient, uh, where the transplanted heart should really come out. And how do you support them without a heart, obviously. 

CATHERINE: Which brings us back to Dr. Bacha and his team at NewYork-Presbyterian. In 2021, they were trained how to implant and monitor the Total Artificial Heart in pediatric patients. The hope was that if a patient came along, who had a heart that needed to be removed – they could save his or her life.

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BACHA: I think we've been waiting for about a year. We had one or two near-misses, so to speak, for using the TAH and then for one reason or another, we couldn't do it.  

CATHERINE: There are many reasons why a patient might not

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be suitable for a total artificial heart. It could be that their chest cavity is too small or some other part of their anatomy isn’t suitable. Dr. Bacha and his team needed to wait… patiently… for the right candidate to come along. 

MUSIC IN

BACHA: I was starting to feel like, oh, we did all the training and then we kind of, uh, invested in the program and then nothing is coming out of it. And then, this, uh, this patient came along, I was excited definitely because I I I I was happy that something was actually happening.

CATHERINE: The patient was a child who originally had been diagnosed with dilated cardiomyopathy. She had already had one heart transplant in her young life. And her body was now rejecting that heart. 

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BACHA: She had a heart transplantation performed several years back, and since her heart transplantation, had been battling with severe rejection episodes... to the point that the medication

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BACHA: needed to control the rejection were so strong that the medication had damaged the kidneys, and we had no other choice but to give her this medication because otherwise she was gonna completely reject her own heart and die. She was in the ICU due to those medications. And so her own transplanted heart was being attacked by her own body. And therefore the ideal solution is somehow to remove the offending organ, so to speak, by removing her own heart and replacing it with a total artificial heart. When you do that, you now, you, you have your total artificial heart in place. You can stop all the, um, anti-rejection medication, give her organs time to recover and specifically her immune system time to sort of rev down, so to speak. You know, the immunological memory is very strong. And maybe forget that, that there, that ever happened so that when we re-transplant her, the, that chronic rejection won't happen again.

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CATHERINE: She was the patient they had been training for. The team began 

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CATHERINE: preparations for the groundbreaking surgery that they hoped would buy her more time, and ultimately, save her life. 

BACHA: Patient selection is a huge part of being successful with this because if you do it for the wrong reasons, you typically have complications. And so you have to, you have to listen and, and, and, and talk to people who've done it before.

CATHERINE: Dr. Bacha had never implanted a total artificial heart before. But that’s not surprising because, in the northeast, no child had successfully been implanted with a total artificial heart. And this particular patient would also be one of the youngest in the world to get the TAH surgery. So, Dr. Bacha consulted with one of his colleagues – Dr. Naka – who had successfully implanted an artificial heart back in 2011, granted – in a slightly older patient. 

BACHA: …and I remember him telling me about that patient who really, just bled after surgery a lot. And it was very, very difficult to control, to control that. That patient that he did also was, was quite a big, uh, teenager.  You know,

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BACHA: I remembered him telling me how bad the bleeding was. And Dr. Naka is an extremely experienced surgeon, so I'm listening to him. I'm thinking if he had, uh, a lot of bleeding, I better make sure we have no bleeding. So typically when you have bleeding from behind the heart, after a heart transplant, you can lift the transplanted heart and then you can look and you can put a suture and fix the bleeding. You can go back on the heart-lung machine, lift the heart. You can do a lot of things. But here, it's like a big metal clump of metal that you're putting in. It's not something you can lift and look behind. And the sutures, the anastomosis are done to both atria in a posterior mediastinum behind that metal pump. And so you can't move it. After you after it's implanted and it's, it's started and pumping blood, you can't lift it. It's a rigid piece of metal that's sitting inside the chest. And so if you have bleeding from the back, the only thing you can do is pack it,

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which is a crude form of control of bleeding. And that's the only thing you can do. But that can take hours and sometimes even days, and you have to sometimes leave surgical packs inside of the chest to control the bleeding and no surgeon wants to be in that situation. The key move is to do, to do everything you can from the get-go to avoid any bleeding at any cost and that was a direct connection with what he had told me about his case. 

CATHERINE: The next step was to select the device. To do so, the team diligently measured the patient’s body – The distance from her spine to her sternum… her body surface area… and all of this calculus led the team to select the 70cc TAH device.

BACHA: So the difficulty in the TAH is making it fit inside a child's chest, right? And it's a very rigid, it's a metal 

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pump, so metal is going to win over any organs that, you know, lungs or esophagus, anything that's around there is going to be compressed by the metal if there's a battle for space between the two. So you have to be really careful about, about space. 

CATHERINE: If everything went according to plan, the patient would have her transplanted heart replaced with the artificial heart. She’d spend some time recovering and rehabilitating in the hospital. And then, eventually she'd be able to go home. Her heart would be connected to a power source that she would wear in a backpack — but besides that,  she would live a relatively normal life, until her immune system had calmed down enough for her body to accept a new transplant. The surgery was scheduled and the team from Syncardia flew in to consult. The patient was prepped and wheeled into the OR. And Dr. Bacha and his colleagues scrubbed in. The surgery took 8 hours. While the surgical team worked, the patient's heart and lungs were powered by a heart-lung machine. The team removed 

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CATHERINE: the transplanted heart that the patient’s body had been rejecting, and began to prepare her body for the artificial heart. The entire time, they were very diligent with their sutures. They needed to make sure there was no excess bleeding. They did not want to experience the same troubles that Dr. Bacha’s colleague had warned him about. 

 

BACHA: And so we spent a lot of time during the implant making sure we had no bleeding. So preventing bleeding. So extra sutures, slow and lots of sutures, lots of felt pledgets and things like that. And, and with, with that, with approaching it that way, with a conscious effort from the step one to avoid bleeding, we were able to avoid bleeding. We really did not have much bleeding at all. And, and that was very gratifying. At some point you have to transition from heart, lung machine support to TAH support and it's a transition that takes five to ten minutes, let's say. And so at some point you turn off the heartline machine completely, 

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and now you're entirely dependent. The patient is entirely dependent on TAH support. In the setting of the, TAH I had never done one, so this was definitely a, a, a special moment. I have this sort of aha moment. I was like, wow, This machine actually works and it's actually able to support the patient's blood pressure and cardiac output and, and, and oxygen delivery to the tissues in a, in a very good way, actually. Very, very good way. I mean, in the end, the, the, the main issue was the space. 

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BACHA: Her chest, uh, was just a little bit too small. We had a really hard time closing her chest after surgery, we had left it open to make sure there was no bleeding. And then when we came to close it, you know, every time we would try to close the sternum, we had to push down the device and then venous return would be impaired and then her flows would go down and she just wasn't tolerating it. 

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I think her, her body, um, morphology was so that her chest was relatively small vis-a-vis the rest of her body. Her belly was pushing up into, into her chest, and so that was obviously to our detriment. 

CATHERINE: As it turned out, the 70 cc device was just slightly… too big. It would be two weeks before they were able to fully close her chest.  

BACHA: So we end up having to do a very slow, step by step closure process over many days. it, it was, uh, it was hairy to do. It was not, not easy. But yeah, I was worried. I mean, you have to be worried. You are worried, obviously, but if you lose it, if you lose your capabilities, then that sends exactly the wrong message to your team. If the head surgeon is running around like a chicken without a head, it's bad. 

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That's a bad problem because everybody's gonna take their cues from you. And then they think, oh my God, if he's panicking, oh my God, this is just terrible. We're never gonna get out of it. So you have to stay calm, even if there's something significantly bad going on, this is I guess, part of, uh, leadership in surgery, which is you have to be able to keep your eye on the prize long-term meaning, okay. What is our goal? Our goal is to close your chest. It's not working in one step. Okay, so let's, let's be patient. Let's work through this. I've been doing this like 25 years, roughly. And so I've encountered situations like this in other settings where, for example, a a patient's heart might be too big after a transplant and you cannot close a chest. And so this is not, uh, brand new except that the TAH was brand new, but the problems with chest closure and space inside the chest 

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wasn't really new to me. And so, you know, you go back to your past experience. I'd done this kind of a bone resection, uh, before and, and then, and then that was eventually what was, what worked for her. It took about, I think about two weeks total. We started closing one part of the chest, the upper sternum, and slowly, slowly, and we end up having to resect some of the, um, anterior chest wall, lower ribs and lower sternum, a little bit posterior wall to uh, uh, to be able to fit it. And eventually we were able to, to close it, and we, you know, we learned lessons along the way. Um, uh, you know, that, uh, certain release maneuvers, technical maneuvers that we could have done earlier or not, and so this, this is all part of the learning process.

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BACHA: The second aha moment is when she's extubated, when the breathing tube came, comes out in the ICU…and you actually realize that, uh, the, her neurological function is intact.

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She's moving everything she's talking, In this particular situation, because it took us so long to get the chest closed, we were worried about infection. We were worried about, uh, a million things. And so to see her awake and, and talking... that, that was special. 

CATHERINE: At the time we spoke to Dr. Bacha, the patient was still in the ICU, but she’s on the right track. Next, she’ll be transferred to a regular hospital room for rehab, and eventually – she’ll go home – with her TAH powered by the backpack that she keeps with her all the time. The hope is that the patient’s artificial heart will only be with her for a short time – a few months maybe — while her body heals and her immune system calms down enough for her to tolerate a new transplanted heart. In other words, she’s still got a long way to go. But the successful implantation of a total artificial heart in this young of a patient signals that other small children with heart failure 

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will now have options they never otherwise would have had. 

MUSIC OUT

BACHA: The work, especially the work of a– in pediatric cardiac surgery can be overwhelming. I mean, there are patients who die, there are patients who have complications, there are immense successes. So it's very, very intense work. When you go to work every single day, you ha- you have to be thinking you have a life that is dependent on you and a child's life. So it's very intense. You do get used to it, believe it or not. I tell my younger colleagues and the residents, what you buy yourself when you go into this field is a portion of your brain will never turn off from the hospital. A portion of your brain, no matter what you're doing outside of the hospital, will always, always be in a hospital thinking about a patient. Is this patient doing well? Is this patient getting through this complication or whatever it is,

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or how can I improve on my surgical skills or what? I mean, there will always be a part of you thinking that.

THEME

BACHA: You cannot do this without the, an entire team. The hallmark of Columbia, New York Presbyterian is the amazing doctors and nurses that I am lucky to work with, and I really mean it. The colleagues that you have here, the dedication that they show and how smart they are and how hardworking they are, is unbelievable. And a lot of credit goes to the nurses in the ICU, a ton of credit goes to them because, you know, we come and go at the bedside, we go and we do our surgeries. But the nurse is the one that's at the bedside eight hours a day, or 12 hours a day, whatever it is. And the nurse is really the, the conduit to the rest of the world at that point in time. And that's a crucial, crucial work that they do without, without nurses and without my colleagues, you know,

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I might as well go do something else. I cannot, cannot do what I do. 

CATHERINE: So many thanks to Dr. Emile Bacha for sitting down with us and sharing his story. I’m Catherine Price; Advances in Care is a production of NewYork-Presbyterian hospital. To find more amazing stories about the innovative physicians at NewYork-Presbyterian, go to nyp.org/advances.

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