DeBAKEy CARDIOvASCuLAR JOuRNAL - Methodist Hospital

Volume 7, Number 1 • Jan. – Mar. 2011 Official publication of Methodist DeBakey Heart & Vascular Center
METHODIST
DeBAKEy CARDIOvASCuLAR JOuRNAL
Looking down on the 36 in x 42 in multi-user
virtual surgical table in Plato’s CAvE using Siemens
flash low-dose CT scan patient data with TeraRecon,
Inc. volume visualization.
PAGE 2 Four Decades of Clinical Experience
Jimmy F. Howell, M.D.
PAGE 19 Private Practice of Cardiac Surgery at The Methodist Hospital
Walter S. Henly, M.D.; John B. Fitzgerald, M.D.
PAGE 21 Three-Dimensional Blood Flow Dynamics: Spiral/Helical
Laminar Flow
Peter A. Stonebridge, Ch.M.
PAGE 27 Plato’s CAvE – Knowledge-Based Medicine or Black Swan
Technology?
Paul E. Sovelius, Jr.
PAGE 35 What Are the Current Risks of Cardiac Catheterization?
Michel E. Bertrand, M.D.
PAGE 40 Initial Clinical Experience of Total Cardiac Replacement with
Dual Heartmate-II ® Axial Flow Pumps for Severe
Biventricular Heart Failure
Matthias Loebe, M.D., Ph.D.; Brian Bruckner, M.D.; Michael J. Reardon, M.D.;
Erika van Doorn, M.D.; Jerry Estep, M.D.; Igor Gregoric, M.D.; Faisel
Masud, M.D.; William Cohn, M.D.; Tadashi Motomura, M.D., Ph.D.;
Guillermo Torre-Amione, M.D.; O.H. Frazier, M.D.
PAGE 45 Pumps and Pipes
Alan B. Lumsden, M.D.; Stephen R. Igo, B.Sc.
PAGE 49 TAvI: Transcatheter Aortic valve Implantation
Neal Kleiman, M.D.; Michael J. Reardon, M.D.
PAGE 53 In Tribute: Ernest Stanley Crawford, M.D.
Hazim J. Safi, M.D.
PAGE 55 Museum of TMH Multimodality Imaging Center
PAGE 57 Abstracts
PAGE 63 My Years with Michael E. DeBakey
Louis H. Green, M.D.
PAGE 64 My Years with Michael E. DeBakey
Larry L. Mathis, M.H.A.
PAGE 65 Poet’s Pen: Why I Am Not a Buddhist
Molly Peacock
PAGE 66 In Memoriam: Michael Thomas McDonough, M.D.
William L. Winters Jr., M.D.
PAGE 67 Letters to the Editor

We Welcome Your
Questions and Comments
W.L. Winters Jr., M.D.
Inquiries, letters to the editor and original
contributions can be directed to MDCvJ@tmhs.org.
Correction Notice
Please note the following corrections for Volume 6, Number 4:
On page 59, the title and institutional affiliation of William
L. Winters Jr., M.D. was incorrect. It states “Professor of
Medicine and Executive Dean, Cleveland Clinic Lerner College
of Medicine of Case, Western Reserve University, George
and Linda Kaufman Chair Chairman, Endocrinology and
Metabolism Institute, Cleveland Clinic, Cleveland, Ohio,” which
are the credential for James B. Young, M.D. It should have
simply read: Methodist DeBakey Heart & Vascular Center,
Houston, Texas.
The statements and opinions expressed in the articles and
editorials included in the Methodist DeBakey Cardiovascular
Journal are those of their authors and are not necessarily
those of the Methodist DeBakey Heart & Vascular Center, The
Methodist Hospital System or affiliated institutions, unless this
is clearly specified.
Methodist DeBakey
Cardiovascular Journal
Volume 7, Number 1, 2011
ISSN 1947-6094
debakeyheartcenter.com/journal
Editor-in-Chief
William L. Winters Jr., M.D.
Managing Editor
Sheshe Giddens, B.A.
Contributing Editor: Poet’s Pen
Michael W. Lieberman, M.D., Ph.D.
Editorial Board
Michel Bertrand, M.D.
Lois DeBakey, Ph.D.
Selma DeBakey, B.A.
Kim A. Eagle, M.D.
Robert A. Guyton, M.D.
Gerald Lawrie, M.D.
Alan B. Lumsden, M.D.
Joseph Naples, M.D.
Craig Pratt, M.D.
Miguel Quiñones, M.D.
Albert Raizner, M.D.
Michael J. Reardon, M.D.
Frank J. Veith, M.D.
James B. Young, M.D.
Methodist DeBakey Cardiovascular Journal (MDCVJ)
provides an update from Methodist DeBakey Heart &
Vascular Center specialists about leading-edge research,
diagnosis and treatments, as well as occasional articles
or commentary by others.
U.S.News & World Report ranks the Methodist DeBakey
Heart & Vascular Center’s cardiology, cardiothoracic and
vascular surgery programs among the best in the nation.
MDCVJ is written for physicians and should be relied
upon for medical education purposes only. It does not
provide a complete overview of the topics covered
and should not replace the independent judgment of
a physician about the appropriateness or risks of a
procedure or treatment for a given patient.
© 2011 The Methodist Hospital
Houston, Texas
Methodist DeBakey Heart & Vascular Center
6565 Fannin Street
Houston, Texas 77030
Telephone: 713-DEBAKEY (713-332-2539)
debakeyheartcenter.com

W.L. Winters Jr., M.D.
EDITOR’S NOTE
editorial
William L. Winters Jr., M.D.
Methodist DeBakey Heart & Vascular Center, Houston, Texas
In this issue, we are privileged to publish the entire
cardiovascular surgical experience of Dr. Jimmy F.
Howell between the years of 1964 and 2004. He was
but one of a remarkable cadre of cardiovascular surgeons
trained by Dr. Michael E. DeBakey during that
period and who worked at The Methodist Hospital in
the academic cardiovascular surgical program at Baylor
College of Medicine (BCM).
The next article by Dr. Henly describes the parallel
development — the first of its kind at The Methodist
Hospital and in Houston — of a private practice cardiovascular
surgical team of surgeons all trained by
the same Michael E. DeBakey, M.D. Simultaneously,
the private practice cardiology community was enlarging
faster than the academic cardiology community
because of the existence of few and small local cardiology
training programs until well into the 1970s. Thus
was laid the groundwork for a strong private practice
medical/surgical cardiovascular network working
and competing in the same close clinical environment
with the academic cardiovascular programs of BCM at
Methodist. As one of our early colleagues commented,
“That environment led to a natural grist between the
private practice groups and the academic Baylor group.”
On the one hand, there was the perceived view by some
of a more personal approach in patient care provided in
the private practice scheme compared to the academic
group. yet in the setting of high tech demands and complex
team requirements, Michael E. DeBakey placed no
barrier to the development of a competing cardiovascular
surgical team. They were, after all, his own trainees
providing the competition. And let no one doubt that
if they had not met the standards set by Dr. DeBakey,
they would not have continued to practice and operate
at The Methodist Hospital. So, as the bar stood high for
cardiovascular surgeons, so it did for cardiologists as
cardiology training programs at BCM, Methodist, and
the Texas Heart Institute began to expand after the
mid-1970s.
As academic surgeons and academic cardiologists
absorbed some of each other’s attributes, private practice
cardiologists and surgeons increasingly became contributors
to the academic programs by participating in
the teaching and research opportunities. The side-byside
growth at The Methodist Hospital of both types of
practices, tolerated by Dr. DeBakey, encouraged by The
Methodist Hospital, and to a lesser degree, by Baylor
College of Medicine, was unique in those early years of
cardiac surgery.
MDCvJ | vII (1) 2011 1

J.F. Howell, M.D.
Foreward
FOuR DECADES OF CLINICAL
EXPERIENCE
JIMMY F. HOWELL, M.D.
Adapted by William L. Winters Jr., M.D., from a monograph published by
Baylor College of Medicine in 2009
Baylor College of Medicine, Houston, Texas
This compilation presents a unique look at the first 40 years of the career of a remarkable cardiovascular
surgeon. One who has refined surgical skills to an unparalleled degree in addressing whatever different
surgical challenges he might encounter in the course of his work. He has maintained a meticulous
and comprehensive record of his surgical experience, which stands as a tribute to him, to the surgical
standards he set and to which he adhered. As one of many of his cardiology colleagues, I feel privileged to
have known and worked with him — as fine a person and physician as I have ever met.
Jimmy Frank Howell, known to The Methodist Hospital community simply as “Jimmy,” was trained in
cardiovascular surgery under the watchful eye of Dr. Michael E. DeBakey, whose strict discipline and
adherence to a high standard of excellence shaped the entire career of Dr. Howell. He accepted an
invitation to join Dr. DeBakey on completion of his training and very quickly developed his own surgical
following.
One of my criteria for assessing the skill of a surgeon is to query nurses in the operating room, intensive
care unit, and the surgical floors. “Still the best hands and judgment around,” is the inevitable assessment
I hear. We all will look back on a career of the remarkable, the Howells and others, with awe, appreciation,
and respect. I know you will enjoy and appreciate reading about the career of a remarkable surgeon —
Dr. Jimmy Frank Howell.
William L. Winters Jr., M.D.
Professor of Medicine
Weill Cornell Medical College
Chief Education Officer
The Methodist Hospital Education Institute
Editor-in-Chief, Methodist DeBakey Cardiovascular Journal
2 vII (1) 2011 | MDCvJ

Every generation has its heroes. Dr. Jimmy Howell vigorously participated in the surge of interest
and the spectacular growth of cardiac and vascular surgery during the DeBakey era and went on to
establish himself as one of the most accomplished and prolific clinical surgeons of his generation. This
text is an important addition to the medical and surgical literature in that it chronicles one of the truly
remarkable individuals in the history of cardiac surgery. In addition to active participation in the explosion
of cardiovascular surgery — with its technological advances including coronary bypass, management
of aneurysmal and peripheral vascular disease, carotid endarterectomy, valve, pacemaker, heart/lung
technology and many more — Dr. Howell contributed to the education, over decades, of generations
of future cardiothoracic and vascular surgeons. His commitment to excellence across four decades of
surgical practice is beyond reproach as evidenced by the outstanding clinical results chronicled on the
following pages. Despite his voluminous surgical schedule and clinical activities, he always has and still
manages to devote the individual attention and care that each patient deserves. In his personal life, he is
a dedicated family man in his roles as husband, father, and grandfather. To this day, Dr. Howell continues
to draw on his wealth of experiences to provide his patients with the highest quality surgical care. We all
remain enormously grateful to these pioneers who provided the foundation for our specialty and for their
careers in cardiac surgery that will never be duplicated.
Joseph S. Coselli, M.D.
Cullen Foundation Endowed Chair
Chief, Division of Cardiothoracic Surgery
Michael E. DeBakey Department of Surgery
Baylor College of Medicine
This issue of the Methodist DeBakey Cardiovascular Journal (MDCVJ) contains a tribute to Dr. Jimmy
Howell in the form a description of his immense cardiovascular experience. Cardiovascular surgery at
The Methodist Hospital was led for many years by Dr. Michael E. DeBakey who is justly remembered by
many as the father of cardiovascular surgery. While many are familiar with Dr. DeBakey’s technical skills
and achievements as a surgeon, fewer people are aware of his keen incite into recognizing and fostering
surgical talent. Dr. Jimmy Howell was one of those surgeons recognized and chosen by Dr. DeBakey to
participate as one of his early partners in developing cardiovascular surgery at Methodist. The work of
Dr. DeBakey, Dr. Howell and others placed Methodist on the world map as a center for cardiovascular
surgery. That legacy has been passed down to shape the Methodist DeBakey Heart & Vascular Center
where Dr. Howell has spent his entire career. I had the singular privilege to have Dr. Howell as one of my
teachers and personally stand in awe of his stellar career. Indeed, at the MDCVJ, we are both extremely
proud and honored to recognize Dr. Howell’s many contributions to the growth of our center and
recognize his importance in shaping its future.
Michael J. Reardon, M.D.
Professor of Cardiothoracic Surgery
Weill Cornell Medical College
Vice Chair, Department of Cardiovascular Surgery
The Methodist Hospital
MDCvJ | vII (1) 2011 3

Introduction
For decades, Baylor College of Medicine’s Department of Surgery, chaired by Dr. Michael E. DeBakey,
has led the way in developing treatments for cardiac and vascular diseases (Figures 1, 2). This document,
presents the personal surgical results of Jimmy F. Howell, M.D., who over the course of 40 years
has performed more than 27,500 cardiac or vascular procedures excluding general and thoracic surgical
opportunities. To this day, now six years beyond the scope of this report, he maintains an active surgical
schedule albeit at a lesser pace (Figures 3, 4). This impressive volume of work was conducted at The
Methodist Hospital, known for its excellence in the treatment of cardiac and vascular diseases — where
the origins of modern vascular surgery came alive with the pioneering abdominal aorta and carotid artery
operations performed by Dr. DeBakey in the early 1950s. The majority of Dr. Howell’s surgical procedures
were performed during the late 1970s to early 1990s, the formative years of cardiac and vascular surgery
at Baylor College of Medicine and The Methodist Hospital (Figures 5, 6).
Acquired heart disease accounted for 43% of patients in this cardiovascular series. Coronary artery
bypass (CABG) operations were the most common procedures. This was due in part to the pioneering
work conducted by the cardiovascular surgeons at Baylor College of Medicine and The Methodist
Hospital in the early 1960s, including the first successful bypass operation performed by Harvey E.
Garrett, M.D. with the assistance of Jimmy F. Howell, M.D. in 1964 with encouragement and support of
Dr. DeBakey (Figure 7). Their work, and the work of others at the Cleveland Clinic Foundation, established
the basis for what is now the most frequently performed heart operation in the world.
Figure 1. Michael E.
DeBakey, M.D.
Figure 4. Jimmy E. Howell, M.D.
Figure 2. Jimmy E. Howell, M.D. Figure 3. Jimmy E. Howell, M.D.
4 vII (1) 2011 | MDCvJ

OTHER CHEST
8.96%
Figure 5. Surgical procedures
Figure 7. 7-year follow-up of the still-functioning bypass graft from
the first successful coronary artery bypass by Drs. Garrett and
Howell at The Methodist Hospital in 1964.
800
700
600
500
400
300
200
100
0
VALVES
8.28%
PVI
10.33%
CVI
10.67%
137
16
10.4%
1965-1975
Cases 153
UPPER EXTREMITY
3.56%
689
GENERAL
SURGERY
17.13%
85
10.9%
1976-1985
Cases 774
CABG
35.07%
CABG with associated
procedures = 2,093
OP survival = 1,851
OP death = 242 11.5%
698
100
12.5%
1986-1995
Cases 798
Figure 9. CABG with associated procedures
327
41
10%
1996-2005
Cases 368
Figure 6. Total cases by year
Figure 8. CABG only; STS benchmark 2002 = 5%, 2006 = 4%
Primary Coronary Artery Bypass
Dr. Howell performed 9,634 primary coronary artery
bypass procedures. There were 9,425 survivors and 209
30-day operative deaths for a 30-day mortality of 2.1%
(Figure 8). During the second and third decades of Dr.
Howell’s practice, the mortality rate for his patients
ranged between 1.7 and 1.9%, well below the national
STS benchmark of 2.6%. The mortality for isolated CAB
in the fourth decade was 2.4%, a slight increase from the
previous three decades attributed to increased complexity
of the cases.
Coronary Artery Bypass with Associated
Procedures
Coronary artery bypass combined with other major
surgical operations comprised 2,093 cases in this series
(Figure 9). The most common additional procedures
were valve replacement or repair, carotid artery recon-
MDCvJ | vII (1) 2011 5
4,000
3,500
3,000
2,500
2,000
1,500
1,000
500
0
1,600
51
3%
1965-1975
Cases 1,651
3,933
80
1.9%
1976-1985
Cases 4,013
CABG only = 9,634
OP survival = 9,425
OP death = 209 2.1%
3.0%
2,726
49
1.7%
1986-1995
Cases 2,775
1,166
29
2.4%
1996-2005
Cases 1,195

Figure 10. Multi-vessel reconstruction employing bilateral internal
thoracic artery and venous grafts.
200
150
100
50
0
0
1
100%
1965-1975
Cases 1
40
10
20%
1976-1985
Cases 50
Redo CABG with
associated procedures = 361
OP survival = 287
OP death = 74 20.4%
Figure 12. Redo CABG with associated procedures
struction, and left ventricular aneurysm repair. (Other
associated procedures included arch aneurysm resection,
lung resection, cholecystectomy, utilization of the
intraaortic balloon pump IABP and 233 other miscellaneous
operations.) The operative mortality remained
little changed over four decades, averaging 11.5% for
these higher risk, complex procedures. Long-term graft
patency studies demonstrated arterial grafts to be superior
to venous grafts at 5- and 10-year follow up. In the
last two decades of the series, almost 100% of patients
received a combination of arterial and venous grafts
particularly in redo coronary artery operations (Figure
10). Internal thoracic and radial arteries were most
frequently utilized.
176
45
20.3%
1986-1995
Cases 221
71
18
18.3%
1996-2005
Cases 87
Figure 11. Redo CABG only; STS benchmark 2002 = 5%;
2006 = 4%
Bjork Shiley
Carpentier
0 250 500 750 1,000
Total operative procedures = 1,516
OP deaths = 96
Figure 13. Aortic valves
Combined carotid and coronary artery revascularization
were performed in 293 patients presenting with
symptoms of both cerebral vascular insufficiency and
coronary artery ischemia or with severe structural
abnormalities of the carotid artery; mortality and morbidity
were 6% in this high-risk group. The rationale of
the combined procedure was to reduce the risk of stroke
near and long term.
Redo Coronary Artery Bypass Alone
Reoperative coronary artery bypass procedures
accounted for 1,077 cases (Figure 11), the majority of
which occurred in the third decade of Dr. Howell’s
practice. There were 1,047 survivors and 30 hospital
6 vII (1) 2011 | MDCvJ
600
500
400
300
200
100
0
20
0
1965-1975
Cases 20
Cutter
DeBakey
Duramedics
Hancock
McGovern
Pericardial
Bioprosthesis
Starr Edwards
St. Jude
Redo CABG only = 1,077
OP survival = 1,047
OP death = 30 2.7%
Unnamed
Values
8
1
8
6
6
25
10
8
271
130
11
3.9%
1976-1985
Cases 282
460
563
14
2.4%
1986-1995
Cases 77
854
193
5
2.5%
1996-2005
Cases 198

Baxter Edwards
Beall
Bjork Shiley
Carpentier
Cooley Cutter
Cutter
Duramedics
Gott
Hancock
Kay Shiley
Pericardial
Bioprothesis
Starr Edwards
St. Jude
Unnamed
Values
1
24
9
6
1
1
6
3
2
44
58
64
111
0
Operative procedures = 789
OP deaths = 78
Figure 14. Mitral valves
250 500
Image provided courtesy of St. Jude Medical Inc.
459
Figure 15. St. Jude mechanical valve and St. Jude biological
tissue valve.
deaths for a 30-day mortality of 2.7%. This mortality
remained well below the STS benchmark of 5% over all
four decades.
Redo Coronary Artery Bypass
with Associated Procedures
Redo coronary artery bypass surgery with associated
procedures was performed on 361 patients (Figure 12).
There were 287 survivors with 74 operative deaths for a
30-day mortality of 20.4%. The added degree of surgical
complexity accounted for the higher risk compared to
redo coronary artery bypass alone. valve replacement,
reconstruction of left ventricular chamber, and carotid
artery revascularization accounted for the majority of
the associated procedures. Intra-aortic balloon pump
was employed in 50% of these procedures.
Valve Operations
Operations on heart valves were performed in 2,745
AVR only = 695
OP survival = 667
OP death = 28 4.0%
Figure 16. AVR only; STS benchmark 2001 = 4.0%
MVR only = 455
OP survival = 424
OP death = 31 6.8%
Figure 17. MVR only; STS benchmark 2001 = 6.5%
cases and consisted of replacement, repair, or a combined
procedure utilizing mechanical or bioprosthetic
valves. A variety of valves were utilized over the four
decades (Figures 13 and 14), with St. Jude mechanical
being the most frequently used (Figure 15).
Isolated aortic valve replacement procedures were
performed on 695 patients. There were 667 30-day survivors
and 28 deaths for a 30-day operative mortality of
4.0% for the four decades. This is comparable to the STS
benchmark of 4% in 2001. However, over the last three
decades, the average mortality averaged 2.7% and distinctly
less than the STS benchmark (Figure 16).
There were 455 operations for isolated mitral valve
replacement; 424 survived and 31 expired for a total
30-day operative mortality of 6.8% compared to the STS
benchmark in 2001 of 6.5%. The 30-day mortality over
the last three decades steadily improved (Figure 17).
Approximately one-sixth of the valve procedures
MDCvJ | vII (1) 2011 7
200
150
100
50
0
200
150
100
50
0
142
13
8.3%
1965-1975
Cases 155
103
12
10.4%
1965-1975
Cases 115
196
5
2.4%
1976-1985
Cases 201
186
13
6.5%
1976-1985
Cases 199
187
6
3.1%
1986-1995
Cases 193
110
5
4.3%
1986-1995
Cases 115
142
4
2.7%
1996-2005
Cases 146
25
1
3.8%
1996-2005
Cases 26

Image provided courtesy of W.L. Gore & Associates, Inc.
Figure 18. Left: Mitral valve repair involving quadrangular resection
of posterior leaflet. Right: Mitral valve repair involving chordal
replacement with Gortex.
150
120
90
60
30
0
123
6
4.6%
1965-1975
Cases 129
111
4
3.4%
1976-1985
Cases 115
Aortic, mitral and tricuspid
Valve repair = 456
OP survival = 435
OP death = 21 4.6%
Figure 19. Aortic, mitral and tricuspid valve repair; STS benchmark
for mitral valve repair 1991 = 4.2%
involved valve repair or reconstruction of the aortic,
mitral (Figure 18), or tricuspid valve. In this group, the
30-day mortality averaged 4.6%, favorably compared
to the STS benchmark for mitral valve repair in 1991 of
4.2% (Figure 19).
Aortic Valve With Associated Procedures
Aortic valve replacements with one or more associated
procedures numbered 806 accounting for more
than 50% of the total Av valve procedures performed.
The most common associated procedures included
CAB, reconstruction of an ascending aortic aneurysm,
or some other valve procedures. There were 741 survivors
and 65 operative deaths for a 30-day operative
mortality of 8.0%, more than doubling the operative
mortality for isolated aortic valve replacement (Figure
20). Similarly with mitral valve replacement, there was
an increase in complexity and comorbidity. There were
334 mitral valve replacements with associated procedures
and 47 deaths for 30-day operative mortality of
14% (Figure 21).
In this series, there were 23 tricuspid valve replacements,
always associated with concomitant aortic or
115
4
3.1%
1986-1995
Cases 119
86
7
7.5%
1996-2005
Cases 93
Figure 20. AVR with associated procedures
Figure 21. MVR with associated procedures
LVA = 376
OP survival = 348
OP death = 28 7.4%
Figure 22. LVA
8 vII (1) 2011 | MDCvJ
250
200
150
100
50
0
150
120
90
60
30
0
200
150
100
50
0
91
15
14.0%
1965-1975
Cases 106
41
239
22
8.4%
1976-1985
Cases 261
232
10
4.1%
1986-1995
Cases 242
AVR with associated procedures = 806
OP survival = 741
OP death = 65 8.0%
13
24%
1965-1975
Cases 54
80
124
20
13.8%
1976-1985
Cases 144
89
9
9.2%
1986-1995
Cases 98
MVR with associated procedures = 334
OP survival = 287
OP death = 47 14%
7
8%
1965-1975
Cases 87
159
12
7%
1976-1985
Cases 171
83
5
5.6%
1986-1995
Cases 88
179
18
9.1%
1996-2005
Cases 197
33
5
13%
1996-2005
Cases 38
26
4
13%
1996-2005
Cases 30

mitral valve operations. In most cases, the tricuspid
valve was replaced with a biologic tissue valve. Two of
the 23 patients receiving tricuspid valve replacement
expired.
Left Ventricular Aneurysm
Reconstruction for left ventricular aneurysm (LvA)
formation following left ventricular (Lv) infarction was
performed in 376 patients with an overall mortality of
7.4% (Figure 22). This operation was performed most
often in conjunction with CABG and repair of postinfarction
ventricular septal defects (vSD). However,
included in this series were 50 patients who had surgery
to repair only the Lv aneurysm, and no mortality
occurred in this group (Figure 23).
In 301 patients, LvA resection was combined with
myocardial revascularization, resulting in improved
30
25
20
15
10
5
0
LVA only = 52
OP survival = 52
OP death = 0
Figure 23. LVA only
150
120
90
60
30
0
29
1965-1975
Cases 29
46
20
0 0 2 0 1 0
4
8%
1965-1975
Cases 50
1976-1985
Cases 20
134
Figure 24. LVA with CABG
8
5.6%
1976-1985
Cases 142
LVA with CABG = 301
OP survival = 281
OP death = 20 6.6%
1986-1995
Cases 2
80
4
4.7%
1986-1995
Cases 84
1996-2005
Cases 1
21
4
16%
1996-2005
Cases 25
long-term results and reducing mortality from 20%
(STS Benchmark) without revascularization to 6.6% with
revascularization (Figure 24).
In this series, 325 patients underwent LvA reconstruction
associated with other procedures such as repair of
a ruptured ventricular wall (Figure 25). There were 298
operative survivors with an 8.3% operative mortality
(Figure 26).
Figure 25. Top: Acute posterior wall infarction with contained
ruptured posterior wall aneurysm. Bottom: Repair of ruptured
posterior wall aneurysm and associated myocardial revascularization.
Figure 26. LVA with associated procedures
MDCvJ | vII (1) 2011 9
150
120
90
60
30
0
51
7
12%
1965-1975
Cases 58
141
11
7.2%
1976-1985
Cases 152
81
5
5.8%
1986-1995
Cases 86
LVA with associated procedures = 325
OP survival = 298
OP death = 27 8.3%
25
4
13.7%
1996-2005
Cases 29

3
Table 1. Post infarction ventricular septal defect
Figure 27. Top: Post infarct VSD with patch graft repair.
Bottom: Surgical exposure of post infarction.
13
11
9
7
5
3
1
0
Operative
Procedure Cases Deaths Mortality
VSD + LVA 11 6 55%
VSD + VA + CAB 8 2 25%
VSD + VA + VALVE 3 0 0%
VSD + CAB 2 0 0%
ALL CASES 24 8 33%
1
1
50%
1965-1975
Cases 3
Figure 28. LVA with VSD
4
2
3.3%
4
1976-1985
Cases 6
LVA with VSD = 29
OP survival = 22
OP death = 7 24%
4
50%
1986-1995
Cases 5
13
0
0%
1996-2005
Cases 4
Post Infarction Ventricular Septal Defect
Mortality after post-infarction ventricular septal
rupture exceeds 90% at one year if untreated. Twentyfour
such defects were surgically repaired during four
decades (Table 1). Acute intervention was the choice in
most of the patients in this series, with outcomes better
than anticipated. More than 70% of these patients were
alive at 24 months. Meticulous surgical techniques minimize
the likelihood of disruption of the suture line or
incomplete repair, which can lead to recurrence of the
defect with resulting high mortality (Figure 27 and 28).
Associated procedures such as coronary revascularization
(10 patients) (Figure 29) and valvular
reconstruction or replacement (3 patients) greatly
improved operative results (Table 1) with overall
33% mortality. Myocardial preservation techniques
improved survival, especially during the last decade
with no operative deaths (13 pts.).
Tumors of the Heart
Since the advent of echocardiography, cardiac neoplasms
have become readily recognizable. And with
cardiac MRI now available, tissue characterization differentiating
benign and malignant cardiac tumors and
thrombus is increasingly possible. This series includes
31 patients with cardiac tumors that were treated surgically.
Cardiac myxoma accounted for 23 of these cases,
with no surgical mortality (Figure 30). (Editor’s Note: I
recall one day when there were three left atrium myxomas
on Dr. Howell’s surgical schedule.) There was one
benign fibroma obstructing the left ventricular outflow
track that was surgically removed and seven patients
operated on for primary sarcoma of the heart. Out of
the 31 patients, the only mortality occurred in two cases
of inoperable sarcoma.
Figure 29. Left: Myocardial infarction with anterior wall aneurysm
and distal ventricular septal rupture. Right: Aneurysm resection and
repair with associated patch graft repair of VSD and myocardial
revascularization.
10 vII (1) 2011 | MDCvJ

Figure 30. Myxoma filling the left atrial cavity with obstruction of
the mitral valve.
Figure 32. Left: Giant right coronary artery aneurysm and associated fistula to the right atrium. Right: Post operative reconstruction with
resection of aneurysm, coronary artery, and closure of fistula to the right atrium.
Miscellaneous Cardiac Operations
The subset of this overall series categorized as miscellaneous
cardiac operations was composed of 852
procedures (Figure 31) that included one or more of
the following: repair of a congenital heart defect (atrial
septal defect, ventricular septal defect, Tetralogy of
Fallot), septal myomectomy for idiopathic hypertrophic
subaortic stenosis (IHSS), subaortic ring, coronary
artery malformation, and pacemaker insertion
(Figure 32).
Pacemaker insertion had the largest number of
patients in this series (568), and the 12 total deaths were
all associated with a myocardial infarction or stroke
occurring after the pacemaker insertion. There were
two deaths in the IHSS group for a mortality of 5.5%.
There was no mortality associated with any of the other
procedures.
Isolated Coronary
Endarterectomy
43
Tetrology
40
Figure 31. Miscellaneous cardiac operations
Carotid Endarterectomy
Coronary Artery
Abnormalities
Supravalvular
Aortic Stenosis
3
Surgery for cerebral vascular insufficiency was first
performed at this institution by Michael E. DeBakey,
M.D., and has continued to evolve over time. Dr. Howell
has performed operations on 3,523 patients for this
condition during the past four decades. Out of those,
3,313 patients were operated on for carotid artery insufficiency
and the remaining cases for vertebral artery
insufficiency. During these four decades, electroencephalography
(EEG) monitoring, first adopted by Dr.
Howell at The Methodist Hospital, has continued as the
gold standard for monitoring cerebral blood flow, thus
avoiding routine carotid artery shunting.
Right or left carotid endarterectomy was performed
in 2,874 patients. There were 26 deaths and 2,848 survivors
with a mortality rate of 0.9% over the four decades.
The mortality after the first decade never exceeded 0.8%,
and the last decade mortality rate was 0.3% (Figure 33).
MDCvJ | vII (1) 2011 11
ASD
119
IHSS
32
VSD
29
18
Pacemaker
568

1000
800
600
400
200
0
450
11
2.3%
1965-1975
Cases 461
Figure 33. RCE & LCE
791
7
0.8%
1976-1985
Cases 798
RCE & LCE only = 2,874
OP survival = 2,848
OP death = 26 0.9%
Figure 34. EEG monitoring during carotid endarterectomy.
Figure 35. Left: Acute occlusion of the left caratid artery with extensive
thrombus formation. Right: Post operative reconstruction with
endarterectomy, thrombectomy, and patch graft angioplasty.
825
5
0.6%
1986-1995
Cases 830
782
3
0.3%
1996-2005
Cases 785
Figure 36. RCE & LCE with associated procedures
This improvement in mortality is attributed to using
intraoperative EEG (Figure 34) while performing patch
graft reconstruction utilizing either vein or bioprosthetic
material (Figure 35).
Right or left carotid endarterectomy with associated
procedures was performed in 439 patients. The most
common associated operations encompassed a CAB
or valve surgery. Operative mortality and morbidity
increased with the combined operation, but even with
this change, the mortality has steadily decreased over
the four decades (Figure 36).
Aneurysmal Disease
Between 1965 and 2005, great vessel aortic resections
were completed in 2,023 patients for aneurysmal disease.
Abdominal aortic resections accounted for 1,532
patients in this series.
Abdominal Aortic Aneurysm
In this series, 964 patients had resection for isolated
aneurysms of the abdominal aorta (AAA) and 568 had
abdominal aortic aneurysm section in combination with
associated procedures (Figures 37 and 38). In the AAA
only group, after the initial decade, the 30-day operative
mortality was less than 2.0% and declined each decade
thereafter (Figure 39). For the AAA group with associated
procedures, the mortality rate declined steadily
after the first decade (Figure 40).
Great Vessels
Great vessel operations on the ascending aorta, aortic
arch, descending aorta, and thoracoabdominal repairs
were performed on 953 patients. Another 31 patients
were operated on for coarctation of the thoracic aortic
for a total of 984 patients.
12 vII (1) 2011 | MDCvJ
200
150
100
50
0
26
2
7.1%
1965-1975
Cases 28
169
10
5.5%
1976-1985
Cases 179
140
6
4.1%
1986-1995
Cases 146
RCE & LCE with associated procedures = 439
OP survival = 418
OP death = 21 4.7%
83
3
3.4%
1996-2005
Cases 86

Figure 37. Left: Preoperative aortogram of abdominal aneurysm with
involvement of renal and visceral vessels with erosion of the spine.
Right: Post operative aortogram following resection of aneurysm with
reconstruction of renal and visceral artery with Dacron graft
and stablization of the spine.
350
300
250
200
150
100
50
0
Figure 39. AAA only
200
150
100
50
0
177
10
5.3%
1965-1975
Cases 187
93
303
6
1.9%
1976-1985
Cases 309
AAA only = 964
OP survival = 940
OP death = 24 2.4%
12
11.4%
1965-1975
Cases 105
152
10
6.1%
1976-1985
Cases 162
295
5
1.6%
1986-1995
Cases 300
198
6
2.4%
1986-1995
Cases 204
AAA with associated procedures = 569
OP survival = 536
OP death = 33 5.7%
Figure 40. AAA with associated procedures
165
3
1.7%
1996-2005
Cases 168
93
5
5.1%
1996-2005
Cases 98
Figure 38. Top: Aneurysm of abdominal aorta with rupture
into inferior vena cava. Bottom: Post operative study following
resection of aneurysm and repair of inferior vena cava.
Uncomplicated Aneurysm of Ascending Aorta
and Aortic Arch
Simple aneurysms of the ascending aorta or the aortic
arch accounted for 153 patients during this four-decade
period. During the formative phase of operations for
complex aortic disease, the operative mortality peaked
at 15% in the third decade before declining drastically
in the fourth decade after the operation became more
refined and standard (Figure 41).
Ascending aorta and aortic arch aneurysm operations
with associated procedures were more the norm, with
a total of 475 patients receiving surgery with this combination.
Coronary bypass and valve replacement were
the most common associated procedures. In this group
as well as that above, the operative mortality declined
during the fourth decade (Figure 42).
Acute dissection of the ascending aorta and arch
were encountered in 61 patients, and all were operated
on emergently (Figure 43). The operative mortality was
31.1% (Figure 44), with 19 of the 61 patients dying from
rupture or complications of rupture. An example of an
acute ascending aortic dissection and rupture into the
right ventricle is displayed in Figures 45 and 46.
MDCvJ | vII (1) 2011 13

60
50
40
30
20
10
0
Figure 41. Aortic aneurysms Figure 42. Ascending aortic aneurysms with associated procedures
Figure 43. Left: Acute type II dissecting aneurysm with subsequent rupture at base of heart. Middle: Method of reconstruction.
Right: Postoperative aortogram and depiction following reconstruction.
15
12
9
6
3
0
19
7
2
9.5%
1965-1975
Cases 21
1
12.5%
1965-1975
Cases 8
12
21
2
8.6%
1976-1985
Cases 23
Ascending aneurysms = 153
OP survival = 138
OP death = 15 9.8%
5
29%
1976-1985
Cases 17
Figure 44. Dissecting ascending aortic aneurysms
8
45
8
50%
1986-1995
Cases 16
Dissecting ascending aneurysms = 61
OP survival = 42
OP death = 19 31.1%
8
15%
1986-1995
Cases 53
15
53
3
5.3%
1996-2005
Cases 56
5
25%
1996-2005
Cases 20
Figure 45. Series depicting the reconstruction of a type II
dissection with rupture into he right ventricle.
14 vII (1) 2011 | MDCvJ
150
120
90
60
30
0
64
15
18.9%
1965-1975
Cases 79
88
15
14.5%
1976-1985
Cases 103
127
28
18%
1986-1995
Cases 155
122
16
11.5%
1996-2005
Cases 138
Ascending aortic aneurysms with associated procedures = 475
OP survival = 401
OP death = 74 15.5%

15
12
9
6
3
0
10
1
9%
1965-1975
Cases 11
Figure 48. Thoracoabdominal aneurysms
7
2
22%
1976-1985
Cases 9
Figure 46.
Patient status post
CABG with acute
type II dissection
with rupture 35 into
the right ventricle
with fistula. 25
5
Resection of
type II dissection
and replacement
of ascending aorta
with Dacron graft,
reimplantation of
venous bypass
grafts, and closure
of the fistula to the
right ventricle.
Thoracic Aneurysms
Descending thoracic aortic aneurysms accounted for
a lesser number of aneurysms in this patient population,
with 142 operated on in this series. Of this number,
37 patients underwent surgery for acute dissection
either because of rupture or acute expansion. In those
patients operated on for a non-dissecting aortic aneurysm
(105), the average mortality rate over the four
decades was 14.2% — ranging from 2.6% in the second
decade to 31.2% in the first decade (Figure 47).
For those operated on for acute dissection of the
descending thoracic aorta (37), the 30-day operative
mortality ranged from 9–23.5% for the first three
decades (Figure 48). There were none performed in
the fourth decade, partly due to the development of
endovascular interventional techniques with graft
13
4
23.5%
1986-1995
Cases 17
Dissecting descending aneurysms = 37
OP survival = 30
OP death = 7 18.9%
15
0
0%
1996-2005
Cases 0
Figure 47. Thoracic aneurysms
Figure 49.
Type III dissecting aneurysm
of the descending thoracic
aorta with post operative
reconstruction utilizing a
Dacron graft.
placement. An example of a type-three dissecting
aneurysm of the descending thoracic aorta is seen in
Figure 49.
Thoracoabdominal Aneurysms
Thoracoabdominal aneurysms present the most
challenging aspects of aortic surgery. Few surgeons
were inclined to make them a routine practice until
E. Stanley Crawford at Baylor College of Medicine
refined the technical aspects to yield a marked
reduction in mortality and spinal cord paralysis. He
publicized his principles in his book, Diseases of the
Aorta. 1 312
There were 122 patients operated on for thoracoabdominal
aneurysms in Dr. Howell’s 40-year
series, with the majority performed during the last
decade. The mortality and morbidity for this operation
has continued to decline (Figure 50). An example
of a thoracoabdominal aneurysm reconstruction is
seen in Figure 51.
MDCvJ | vII (1) 2011 15
40
30
20
10
0
22
10
31%
1965-1975
Cases 32
37
1
2.6%
1976-1985
Cases 38
Descending aneurysms = 105
OP survival = 90
OP death = 15 14.2%
24
2
7.6%
1986-1995
Cases 26
7
2
22%
1996-2005
Cases 9

60
50
40
30
20
10
0
5
2
28.5%
1965-1975
Cases 7
Figure 50. TAAA
12
5
29%
1976-1985
Cases 17
TAAA = 122
OP survival = 104
OP death = 18 14.7%
Vascular Occlusive Disease
Surgical reconstruction for both aortic and peripheral
vascular occlusive disease was performed in 2,383
patients in this series. Reconstruction of the aortic or
iliac segment of the aorta for occlusive disease was
accomplished in 1,016 patients (Figure 52).
Leriche Syndrome
In this situation, indications for surgery were either
significant claudication or tissue loss in the lower
extremities. Dacron bifurcated grafts were utilized in
the majority of these cases, with endarterectomy and
patch grafting to a lesser degree. Overall 30-day operative
mortality of 1.1% was constant over four decades.
The most common associated procedures were renal
artery and visceral reconstruction with Dacron grafts
(Figures 53 and 54).
Figure 51. Left: Extent III TAAA involving the thoracic and abdominal aorta. Middle: Method of reconstruction with reimplantaton of intercostal,
visceral and renal arteries. Right: Post operative aortogram and depiction of completed repair.
Figure 52. Patient with aortoiliac
occlusive disease with associated
occlusion of celiac and SMA and chronic
visceral insufficiency. Post operative
aortogram demonstrating a functioning
aorta, bilateral femoral, celiac and
superior mesenteric arteries.
36
5
12%
1986-1995
Cases 41
51
6
10.5%
1996-2005
Cases 57
Figure 53. Total occlusion of
the abdominal aorta. Thromboendarterectomy
and reconstruction
of the aorta with a bifurcated Dacron
graft to the femoral arteries.
Figure 54. LERICHE
16 vII (1) 2011 | MDCvJ
400
350
300
250
200
150
100
50
0
312
5
1.5%
1965-1975
Cases 317
362
3
0.8%
1976-1985
Cases 365
LERICHE = 1,016
OP survival = 1,004
OP death = 12 1.1%
242
3
1.2%
1986-1995
Cases 245
88
1
1.7%
1996-2005
Cases 1,195

Lower Extremity Revascularization
Revascularization of the femoral, popliteal, and tibial
segments was accomplished in 1,367 patients with a 1%
30-day operative mortality over four decades (Figure
55). Femoral popliteal and femoral tibial bypasses were
performed with a multitude of graft materials including
Dacron, Gore-Tex, homologous saphenous vein, and
autologous saphenous vein. Other patch graft material
included pericardium. Autologous saphenous vein
proved to be the material of choice and has been used
with excellent long-term results for the past 30 years
(Figures 56 and 57).
Tibial vessel reconstruction is usually reserved for
gangrene or tissue loss of the lower extremities. The
material of choice is autologous saphenous vein
(Figure 58).
Figure 56. Superficial femoral artery obstruction with saphenous vein bypass
graft reconstruction.
Figure 58. Concepts of reconstruction of
anterior or posterior tibial vessels utilizing
saphenous vein grafts.
Figure 55. FEM-POP’s with associated procedures
Figure 57. The first documented (1964)
anterior tibial bypass and post operative
arteriogram demonstrating functioning graft.
MDCvJ | vII (1) 2011 17
400
350
300
250
200
150
100
50
0
383
3
0.7%
1965-1975
Cases 386
338
2
0.5%
1976-1985
Cases 340
365
6
1.6%
1986-1995
Cases 371
FEM-POP’s with associated procedures = 1,367
OP survival = 1,353
OP death = 14 1%
267
3
1.1%
1996-2005
Cases 270

Visceral Artery Reconstruction
visceral artery reconstruction (bypass graft, patch
graft) for acute or chronic visceral artery insufficiency
was performed in 70 cases. Superior mesentary artery
bypass was the most common operation, and the least
performed was a combination of superior mesentary
artery and celiac artery reconstruction (Figure 59). There
was no operative mortality with this series.
Isolated renal artery reconstruction for intractable
hypertension was performed in 275 patients with no
operative mortality.
Miscellaneous Vascular Operations
Other miscellaneous vascular operations were performed
in 1,975 patients. These procedures included
embolectomy, thromboembolectomy, sympathectomy,
upper extremity reconstruction for occlusive vascular
disease, and/or aneurysm resection and arterial venous
malformations (Figure 60). There were 19 deaths following
embolectomy or thromboembolectomy of the aorta
or lower extremities. Another 17 died of postoperative
myocardial infection and two of stroke in this series.
One death occurred following pulmonary embolization
secondary to repair of an Av fistula of the lower
extremity. The total of 20 deaths in this series represents
a 0.01% mortality rate.
References
1. Crawford, ES, Crawford, JL; Diseases of the aorta.
Williams and Wickens. Baltimore, MD. 1984.
Figure 59 Top: Localized obstruction of the aorta and involvement
of the SMA with visceral artery insufficiency. Bottom: Follow up
aortogram demonstrating post operative endarterectomy with
functioning SMA bypass graft.
Figure 60. Top: Subclavian artery obstruction with embolization
secondary to cervical rib compression. Bottom: Resection of
cervical rib and segment of 1st rib with resection of subclavian
obstruction with graft interposition.
18 vII (1) 2011 | MDCvJ

W.S. Henly, M.D.
PRIvATE PRACTICE OF CARDIAC SuRGERy
AT THE METHODIST HOSPITAL
Walter S. Henly, M.D. a ; John B. Fitzgerald, M.D. b
From a The Methodist Hospital and b St. Joseph Hospital, Houston, Texas
In the mid-1960s, the practice of cardiac surgery outside
of a medical school environment was a foreign
concept. Graduates of approved university programs
had to look to other academic programs in order to
practice their newly acquired skills. In 1965, four surgeons,
recently trained within the Baylor College of
Medicine’s residency program, entered into an association
that would venture into this new frontier.
Surgical Associates was the third professional medical
association formed in the city of Houston; the first
was a radiological group practicing at St. Joseph’s
Hospital, and the second was the obstetrical/gynecological
physicians practicing in the Texas Medical Center.
The purpose of Surgical Associates was to provide
quality care to patients needing cardiac, thoracic, and
vascular surgery within an environment of private practice.
The founding partners of this association were Drs.
Robert C. Overton Jr., John B. Fitzgerald, Don C. Quast,
and Walter S. Henly. All were trained in their specialty
under the supervision of Dr. Michael E. DeBakey, professor
of surgery and chairman of the Department of
Surgery at Baylor.
Since Baylor owned the heart-lung machines within
The Methodist Hospital and paid the perfusionists, the
decision was made not to avail these services to this
new group in private practice. A request for support
was made to the administration of the hospital and
found favor with President Ted Bowen and members of
Methodist’s board of directors.
To his credit, Dr. DeBakey did not try in any way to
prevent this direct competition with the Baylor surgery
department. While he stopped short of possibly endorsing
our endeavor, he made no overt effort to hinder our
progress. Perhaps he was secretly proud that a group
of his trainees was taking this step, which obviously
had to come some day. Thus, necessary equipment was
ordered in preparation for the first patient. The day
after the heart-lung machine was uncrated and tested,
an atrial septal defect was successfully repaired with
Dr. Fitzgerald acting as perfusionist.
Dr. Fitzgerald has described this initial event in
this manner: “The pump was delivered to the loading
dock at The Methodist Hospital the afternoon
before our first case was scheduled. We worked well
into the night uncrating and assembling the equipment.
I had learned to operate a pump-oxygenator
while serving in the Air Force when assigned to the
Experimental Surgery Department of the School of
Aerospace Medicine. To this day, I have no clue as to
why the School of Aerospace Medicine owned a heartlung
machine, but they did, and I had plenty of time to
tinker with it and learn how to set it up and operate it.
Therefore, by default, I became the perfusionist for our
team. The following morning, the case got underway
without difficulty. The heart was cannulated in preparation
for bypass. However, when it came time to initiate
cardiopulmonary bypass, we were unable to lower the
oxygenator enough to obtain good venous drainage. We
were left with only one alternative: to raise the patient.
By elevating the operating table to its maximum height
and placing the entire surgical team on the highest platforms
available, we were able to institute adequate flow
for bypass. The operation proceeded smoothly, and the
patient recovered without incident.” 1
Ms. Shirley Bryson, a former Baylor perfusionist,
came out of retirement to assist with subsequent cases
and to train additional pump technicians. One trainee,
who served well for many years, was Mr. E. J. Donnelly.
He trained numerous perfusionists to work in other
institutions throughout the state.
In the early days, patients needing valve replacement,
those with aortic aneurysms and dissection, and
those with coronary artery disease were accepted for
treatment. Aortic and mitral valves were replaced with
Starr-Edwards ball valve prostheses until the bileaflet
St. Jude Medical valves were proven superior. various
MDCvJ | vII (1) 2011 19

types of aortic dissections and thoracic aneurysms were
managed, some with the aid of the heart-lung machine
and others with left atrial-femoral bypass techniques.
The earliest attempts to improve the myocardial circulation
in patients with coronary artery disease were
by utilizing the vineberg procedure. 2 This operation
involved implanting a bleeding internal mammary
artery into a left ventricular myocardial tunnel, trusting
that vascular connections between the graft and the
myocardium would develop. In 1964, Drs. DeBakey and
H.E. Garrett performed the first successful vein bypass
to a coronary artery. 3 The value of this was not appreciated
until Drs. Rene Favalaro 4 and Dudley Johnson 5
independently published their series of bypass procedures
in 1967–1969. Surgical Associates performed their
first coronary artery bypass successfully in 1969.
Having a private cardiac service and a university
cardiac service in the same institution provided competitive
advantageousness — for example, the use of
the internal mammary artery as a bypass conduit for
CABG. Some cardiologists and cardiac surgeons were
outspoken against this. At a meeting of the Houston
Society of Cardiologists, this subject came under discussion.
One Baylor surgeon stated that taking the
mammary took excessive time and increased morbidity.
It was Dr. Denton Cooley who spoke of the value of an
arterial graft. This seemed to change the minds of some
cardiologists, for patient referrals became easier for the
private practice service after that. When Dr. Garrett
left Houston for Memphis, he stated to one colleague
at Surgical Associates that we should “continue to use
mammaries and we will be doing a superior operation.”
Not long after, mammary use became the keystone of
coronary bypass surgery.
Surgical Associates chose to stay as close as possible
to new developments in the field of cardiac surgery.
Newer techniques such as cardioplegia, antegrade
coronary artery perfusion, retrograde coronary sinus
perfusion, and numerous other advances were used
in practice as soon as proven safe. It was necessary to
maintain an active service within a quality hospital
such as Methodist in order to permit scrutiny of our
work by peers since private services were being developed
in other Houston hospitals. As the practice grew,
additional surgeons were added, including Drs. Richard
K. Ricks, Charles H. McCollum, Antoinette C. Ripepi,
Richard C. Geis, and Michael J. Reardon.
As Houston was growing, Surgical Associates
opened active cardiac services at Hermann Hospital, St.
Joseph Hospital and Memorial Hospital. These major
hospitals began to update their intensive care units
and cardiac catheterization laboratories. The city-wide
practice increased to the point that two surgeons were
always available for surgical operations and night and
weekend call. Two factors were important to our success:
1) our primary service remained at The Methodist
Hospital, where all of our academic peers ensured that
our work was subject to professional scrutiny, and 2)
we had two trained surgeons physically present at
the operating table for every procedure, and one of us
would remain in the hospital with the patient until
everything was stable. This often entailed sitting with
the patient through the first 24 to 48 hours after surgery.
Looking back over the past 45 years, 6 our practice flourished
and, of necessity, our association began to divide.
Some left to lead in other institutions, some returned to
academia, and some remained working at Methodist.
under the management of Dr. DeBakey’s successors,
the private cardiac surgery service was merged
with the university service in Methodist’s Fondren-
Brown operating areas. This move seemed motivated by
cost-control factors, although some of the competitive
advantages of having an independent private service
were lost in the process. Of great satisfaction is the realization
that Surgical Associates opened doors for many
cardiac surgeons to practice their skills. This proved to
be of particular importance as techniques for successful
coronary bypass operations were perfected, since this of
itself produced an explosion in the number of patients
needing cardiac surgery, a need that could not be met
by academia alone.
References
1. Mattox KL. The History of Surgery in Houston. Austin,
TX: Eakin Press; 1998.
2. vineberg A. Coronary vascular anastomoses by internal
mammary artery implantation. Can Med Assoc J. 1958 Jun
1;78(11):871-9.
3. Garrett HE, Dennis EW, DeBakey ME. Aortocoronary
bypass with saphenous vein graft. Seven-year follow-up.
JAMA. 1973 Feb 12;223(7):792-4.
4. Favaloro RG. Saphenous vein autograft replacement of
severe segmental coronary artery occlusion: operative
technique. Ann Thorac Surg. 1968 Apr;5(4):334-9.
5. Johnson WD, Flemma RJ, Lepley D Jr, Ellison EH.
Extended treatment of severe coronary artery disease: a
total surgical approach. Ann Surg. 1969 Sep;170(3):460-70.
6. DeBakey ME, Henly WS. Surgical treatment of angina
pectoris: a fifty year retrospective from Baylor/Methodist.
Methodist Debakey Cardiovasc J. 2008;4(2):1-7.
20 vII (1) 2011 | MDCvJ

P.A. Stonebridge, Ch.M.
Introduction
THREE-DIMENSIONAL BLOOD FLOW
DyNAMICS: SPIRAL/HELICAL LAMINAR
FLOW
Peter A. Stonebridge, Ch.M.
University of Dundee, Scotland
Recent work in cardiac and peripheral vascular blood flow has
shown evidence for an elegant complexity to flow within the heart
and in the large to medium arteries. Blood flow is normally described
as laminar in that the blood travels smoothly or in regular paths. The
velocity, pressure, and other flow properties at each point in the
fluid remain constant, all parallel to each other. Our understanding
has revolved around a two-dimensional representation of flow within
three-dimensional (3-D) blood vessels. However, MRI and color
Doppler flow imaging techniques have demonstrated that there is a
spiral/helical/rotational property to laminar blood flow. (In this article,
this blood flow profile will be termed spiral laminar flow though all are
equally valid terms.) The column of blood turns on a central axis as it passes along the major
arteries (Figure 1).
Heart
The heart is a remarkable structure that displays a
twisting/wringing motion during emptying and early
filling, in part due to counter-wound helical muscle
fibers. Much of this underlying principle has been
known for 500 years, the helical nature of myocardial
fibers being described by Lower in the second half of
the 17th century. More recently, Buckberg focused on
linking cardiac helical anatomy with cardiac function
based on work by Torrent-Guasp concerning the 3-D
nature of left ventricular myocardial structure. 1, 2 This
is encompassed in the concept of the “helical” pump
or heart. The heart appears to operate as a spiral-compressive
pump with the wall following a spiral descent
rather than a direct linear move to the center (Figure 2). 3
The spiral trabecular configuration of the internal surface
of the left ventricle demonstrated by Gorodkov
may also have a role. 4 This twisting motion during contraction
is believed to result in more efficient cardiac
Figure 1. Two-dimensional versus threedimensional
representation of laminar flow in
a tube.
emptying, with blood ejected from the left ventricle
having a rotational element. It can be argued that
having a rotational element to flow has the additional
advantage of imposing a laminar order rather than the
natural “settling out” of turbulence. Eliminating turbulent
flow may also be important with respect to cardiac
work since turbulent flow is more resistant to pumping,
requiring more energy to move the fluid and therefore
more work for the heart. The concept of the ‘helical
heart’ therefore could be anticipated to have advantages
in terms of efficient emptying and efficient energy use.
Interestingly, Leonardo da vinci appears to have
come to a similar conclusion with respect to spiral
cardiac emptying as he sketched what very much
appears to be spiral flow being generated within the left
ventricle of the heart in the 16th century.
Aorta
Modern imaging techniques have shown spiral
MDCvJ | vII (1) 2011 21

LV
Contraction / expansion
Figure 2. MRI images of left ventricular myocardial motion and
interpretation. From: Jung B, Markl M, Föll D, Hennig J. Investigating
myocardial motion by MRI using tissue phase mapping. Eur J
Cardiothorac Surg. 2006;29 Suppl 1:S150-7.
laminar flow within the ascending, arch, descending
thoracic and abdominal aorta. 5-11 A clockwise rotation
has been demonstrated during systole, although a counter-clockwise
rotation has been shown in diastole in the
descending aorta. 12
As there is spiral flow within the ascending aorta, the
nonplanar arch of the aorta appears not to be the prime
initiator of this flow profile. It is likely, however, that it
reinforces and propagates this 3-D flow pattern through
wall motion, compliance, and the tapering nature of the
aorta. 13
The spiral flow axis line is at the center line of the
aorta. This is thought to play a significant part in maintaining
the blood flow direction passing through the
curved aortic arch, keeping the most effective ejection
as well as in dispersing the shear stress in the aortic
wall. 14
Lee J. Frazin, 20 years ago, concluded that spiral
flow may affect organ perfusion and that the rotational
element of flow should be taken into account when
studying flow within the aorta. 7 Recent numerical analyses
of the impact of spiral flow within the aorta have
concluded that the flow profile may indeed have physiological
significance in the aorta. It is predicted to play
a positive role in the transport of oxygen by enhancing
oxygen flux to the arterial wall. It reduces the luminal
surface LDL concentration in the aortic arch and probably
plays a role in suppressing severe polarization of
LDL at the origins of the three branches on the arch,
therefore protecting them from atherogenesis. 15, 16 A
study examining the effect of spiral flow on the uptake
of LDL on a straight segment of rabbit aorta arrived at
a very similar conclusion: that spiral flow in the arterial
system plays a beneficial role in protecting the arterial
wall from atherogenesis. 17
Passing into the abdominal aorta, a further numerical
study of spiral flow within the aorta showed a beneficial
effect on the nature of flow within the iliac vessels.
There were no regions of flow separation and decreased
differences in the shear stress between the inner and
outer walls in the iliac arteries. Spiral flow appears to
impart a stabilizing effect on flow patterns in the downstream
branches of the aorta. 18
Peripheral Arterial
In 1991, parallel work related to blood flow in arteries
led to the suggestion that the normal physiological
blood flow pattern may in fact be spiral laminar flow. 19
The 3-D nature of blood flow was demonstrated in
more peripheral and superficial arteries using colorflow
Doppler. A true transverse plane, color Doppler
interrogation of blood vessels at low velocity settings
shows a characteristic appearance — the “red/blue
split” (Figure 3). 20 This has been shown to represent
spiral laminar flow with its axis at the centre of the
artery, which has been termed “spiral laminar flow.” It
is important to emphasize that the flow profile is not
only rotating but also laminar for the characteristic profile
to exist. using this methodology, this distinctive
appearance and therefore flow profile has been reported
in relatively superficial vessels such as the femoral and
carotid arteries. 21 Magnetic resonance angiography
(MRA) can be used in a similar way to interrogate the
carotids, revealing the same 3-D flow profile. 22
The peripheral arterial tree beyond the aortic arch
also has significant elements of nonplanar construction
that may play a role in the occurrence of spiral laminar
flow. 23 It is also interesting to note that the arrangement
of the muscle and elastin fibers of the arteries have been
shown to be in helical arrangement. 24 Whether this is a
coincidence or has a more direct relationship with the
nature of flow in the vessel is as yet unknown.
Figure 3. Arterial color Doppler of a transverse view of the common
femoral artery and a graphic representation.
22 vII (1) 2011 | MDCvJ

As a consequence of the above work, it is now possible
to bring left ventricular anatomy and function
together with blood flow within large-to-medium
arteries as a coherent beneficial flow system. Cardiac
architecture causes the left ventricle to “wring/squeeze”
the heart empty, acting as a kind of spiral-compressive
pump. This ejects the blood flow from the left ventricle
through a nondiseased aortic valve with a spiral laminar
flow profile. This flow pattern has been shown to be
preserved as it passes around the arch of the aorta and
into the descending/abdominal aorta, which may in
part be due to the nonplanar nature of the aortic arch.
Finally, spiral laminar flow has been identified within
more distal direct line vessels (femoral arteries) and
branch vessels (carotid arteries). Spiral flow may also
have beneficial effects on cardiac work and tissue oxygenation
and in the protection of the arterial wall from
atherogenesis.
Clinical Correlation
When assessing the significance of spiral laminar
flow, it is important to show a causal relationship with
the development of arterial disease. There is very little
work in this area and it is more circumstantial than
definitive.
The loss of spiral blood flow has been associated with
the presence, severity and progression of atheromatous
disease. 25, 26 However, it should be stressed that this is
an association and not proof of a causal relationship. A
long-term mapping of flow patterns against disease and
its progression is required, and this has not been performed
as yet.
Flow Analysis and Vascular Stents and
Grafts
Hemodynamic forces are a key localizing factor in
arterial endothelial dysfunction and, as a result, arterial
pathology. 27 Low shear stress appears to be one of the
key components of this flow/vessel wall interaction. 28 In
1993, Zarins et al. demonstrated that intimal thickening
and atherosclerosis develop in regions of relatively low
shear stress and variation from axially aligned unidirectional
flow. 29 Stonebridge and Brophy hypothesized that
spiral flow could exert a beneficial effect on the mechanisms
of endothelial damage and repair. 19 A study by
Caro et al. supported this hypothesis and demonstrated
that spiral flow may lead to relative uniformity of wall
shear and inhibition of flow stagnation, separation and
instability. 30
Spiral flow has also been shown to preserve laminar
flow through stenoses (“laminar stability”), markedly
Figure 4. Laminar stability — nonspiral (upper) and spiral (lower)
MRI image of flow through a stenosis showing loss of image with
nonspiral flow and preservation of image with spiral flow. 31
reducing turbulent kinetic energy (Figure 4). It also
reduces laterally directed forces impacting on the vessel
wall. Spiral laminar flow generates a thin, less-dense
(probably acelluar) outer shell, which may act as a “fluid
bearing” for the denser inner core, again assisting in
31, 32
reducing rotational decay.
One study investigated the magnitude of oscillating
shear stress in an aortocoronary bypass computer
model in the presence of spiral flow. A linear inverse
relationship was found between the oscillating shear
index and the helical flow index for the models. The
results indicated that spiral flow damped the wall shear
stress temporal gradients within the proximal graft. The
authors suggested that spiral flow might play a significant
role in preventing plaque deposition by moderating
the mechanotransduction pathways of cells. They further
concluded that the strength of the spiral flow
signal could be used to risk stratify for the activation of
mechanical and biological pathways leading to fibrointimal
hyperplasia. 33
A graft or stent that recreates spiral flow at the distal
anastomosis/outflow might be anticipated to have some
benefits. A numerical analysis based on a spiral flow
inducer for endovascular stents showed that the inducer
could create sufficiently strong spiral flow, effectively
MDCvJ | vII (1) 2011 23

educing turbulence created by the stent, so that arterial
restenosis due to the stent implantation might be suppressed.
34
The manner in which these findings can be of importance
to prosthetic graft design relate to the outflow
from prosthetic grafts. Many prosthetic grafts fail due to
neointimal hyperplasia at the distal anastomosis, which
eventually occludes outflow. One hypothesis tested by
stents and grafts, which engender spiral flow, is that the
endothelial cells at the distal outflow are sensitive to the
flow environment. Neointimal hyperplasia may in part
or whole be a normal distal anastomotic endothelial cell
mechanosensory response to an abnormal flow environment
(nonlaminar flow, i.e., turbulence, stagnation,
oscillatory shear stress). Reducing any flow-mediated
drive to neointimal hyperplasia would be anticipated to
prolong graft patency.
Spiral flow has also been shown to increase the blood
velocity near the vessel wall and the wall shear rate.
This is thought to potentially reduce acute thrombus
formation and intimal hyperplasia and thereby improve
graft patency rates. 35 A second study, using a simplified
model of a stent within a straight segment of an
artery in which spiral flow was introduced, showed
that this flow reduced the size of the disturbed flow
zones, enhanced the average wall shear stress, and lowered
oscillatory shear index in the stent. All of these
are believed to be adverse factors in the development of
arterial restenosis after stent deployment. 36 Interestingly,
the minimum rotational velocity of the spiral flow
required was approximately 6.5 cms/sec, which is very
similar to that shown in femoral arteries of healthy
volunteers. 21
One of the major causes of early failure of smallcaliber
artificial vascular grafts is acute thrombus
formation, in which the interaction of platelets with
the grafts’ thrombogenic surfaces is the initiating step.
According to Sauvage, the action of shear forces can
prevent thrombus from forming on the graft wall if the
blood flow in the graft is higher than the thrombotic
threshold velocity. 37 unfortunately, blood flow rates in
small-diameter grafts are small, usually resulting in a
time average velocity of blood flow in these grafts to
be below this thrombotic threshold velocity. Enhancing
blood velocity near the wall of a graft by inducing spiral
flow may overcome this acute thrombus problem and
may be a solution to increasing the patency of smalldiameter
vascular grafts. A recent study showed that
spiral flow generated less adhesion of platelets to the
inner surface of a tube when compared with nonspiral
flow. The authors concluded that intentionally introducing
spiral flow in small-caliber arterial grafts has no
adverse effect on platelet activation and may indeed be a
solution to improving the patency of the grafts by
suppressing acute thrombus formation. 38
Whether the artificial engendering of spiral laminar
flow has biological advantages has yet to be definitively
answered. If endothelial cells are sensitive to juxtamural
turbulence, areas of stagnation, stress gradients, and/
or high oscillatory shear stress, then the stabilization of
laminar flow is likely to be an advantage. The delivery
of stabilized spiral laminar flow from prostheses has
not been possible until recently and therefore could
benefit from further research.
Conclusion
Spiral laminar flow is an elegant unified flow concept.
There are a number of published features of spiral
laminar flow, indicating that this flow profile may have
advantages over nonspiral flow in both physiological
(heart and the peripheral artery) and device-related flow
(Table 1). It is possible to speculate about other potential
beneficial properties but these have as yet not been
tested. There is, therefore, a lot more work to be done in
this field. Only more research and time will determine
whether or not it is something of true significance.
Laminar stability
Reduced laterally directed forces
Reduced near-wall turbulence
Suppresses acute thrombus formation with no increase in
platelet activation
Enhances oxygen flux to the arterial wall
Reduces luminal surface LDL concentration
Dampens wall stress temporal gradients
Lowers oscillatory shear stress index
Table 1. Published features of spinal laminar flow
24 vII (1) 2011 | MDCvJ

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26 vII (1) 2011 | MDCvJ

P.E. Sovelius Jr.
Overview
PLATO’S CAvE — KNOWLEDGE-BASED
MEDICINE OR BLACK SWAN
TECHNOLOGy?
Paul E. Sovelius Jr.
The Methodist Hospital, Houston, Texas
Plato’s CAVE TM is a presurgical planning, multidimensional “life space situation room” designed, developed,
and introduced to clinical practice by the Department of Radiation Oncology at The Methodist
Hospital, located in Houston’s Texas Medical Center. At approximately 500 square feet, Plato’s CAVE
was specifically designed to permit a team of physicians to review all available diagnostic images of the
patient (Figures 1a, 1b). The initial clinical focus was for interventions within the domain of surgical oncology,
including radiation therapy, reconstructive surgery, and organ transplantation. This advanced clinical
visualization process, supported by a novel and creative assemblage of FDA-approved, commercially
available diagnostic imaging components, is available for all relevant patient care services within The
Methodist Hospital System.
Figure 1a. Inside Plato’s CAVE with large screen and virtual
surgical table visualized with TeraRecon, Inc.
Figure 1b. Inside Plato’s CAVE with large screen and laptop
integrated visualization by BodyViz, Inc.
The underlying concept is that of a military flight simulator. As opposed to a commercial flight simulator, a
fighter pilot environment is a multi-body simulation that records all of the plane’s internal instruments and
the pilot’s actions with the digital fly-by-wire avionics system; its external position in relation to its global
position; and, with GPS, the absolute spatial (X, Y, Z) position of the squadron and the aggressor(s) within
its three-dimensional sphere of influence. This well-vetted process of recording input/output variables and
resultant differences along the flight path of interaction is critical for pilots to learn from each other’s experience
what works well and what should be improved, all within a real-time frame of reference for action
and reaction. The knowledge gained is now being used by unmanned aerial vehicles that are remotely
piloted, not unlike the da Vinci surgical robot.
MDCvJ | vII (1) 2011 27

Figure 2. “The Visible Human”
from the1995 National Library of
Medicine, rendered with Fovia, Inc.
Figure 3. Archimedes
Circulatory System from 287 B.C.
Plato’s CAVE: Conceptual Beginnings
I first designed the single-user surgeon computeraugmented
virtual environment (CAvE) concept in 2006
as the sole proprietor of a 20 ft x 15 ft glass-walled kiosk
that was to be installed within one of The Methodist
Hospital System’s professional buildings. Initially
called the Surgeons EDGE TM , it was designed for cardiovascular
surgeons who did not have the time or
tools necessary to manipulate and integrate a series of
patient-specific CT angiography (CTA) studies into an
interactive 3-D volume that could be used to measure
aortic grafts for individual patients. With the encouragement
of Drs. Richard Geis, Samuel Henly, and Alan
Lumsden, I designed a kiosk near the OR where cardiovascular
physicians could fit aortic grafts to their
patients on a 24/7 basis. The kiosk was to be fitted with
a state-of-the-art 3-D TeraRecon large-screen workstation,
and my role evolved into an “aorta tailor” who
works with the physicians and sets up the procedure for
measurement and validation.
In 2007, Drs. E. Brian Butler and Alan Lumsden were
collaborating with IBM on a research project called the
“virtual Patient.” They were attempting to use the
National Library of Medicine’s MRI-based visible
Human Project ® as a base map for a detailed, imageguided,
auto-segmented atlas of patient-specific CTAs
(Figures 2 and 3). The visible Human Project involved the
creation of complete, detailed, 3-D representations of the
male and female human bodies using CT and MRI slices.
Lumsden and Butler built on this concept with the
acquisition of transverse CT, MR, and cryosection
images of representative male and female cadavers.
The male was sectioned at one-millimeter intervals, the
female at one-third of a millimeter intervals; this level
of resolution still exceeds the standard of care today.
The virtual Patient data set, with its detailed crosssectional
pathology photographs, was coregistered
with medical imaging data sets of the body. The 3-D
reconstructed virtual cardiovascular images were then
automatically labeled and subsequently tagged with
SQuID (superconducting quantum interference device)
detectable anatomical markers for the proposed intraoperative
image-guided system.
This process was designed to assist Drs. Lumsden
and Butler in creating a vascular roadmap for the targeted
delivery of a gene therapy “package” that could
be activated with a time-release viral agent designed
by Dr. Butler. Before it could be concluded, it was put
on hold for two reasons: Dr. Butler was named chairman
of the newly formed Department of Radiation
Oncology at The Methodist Hospital, and Dr. Lumsden
was named chair of Methodist’s Department of
Cardiovascular Surgery. In order to keep the project
moving, both doctors asked me to work full-time with
Dr. Butler at The Methodist Hospital and to look outside
the box for nonclinical engineering solutions to the
image-guided delivery system based on my previous
scientific visualization experience.
I have worked for many years providing the visual
system hardware and software for real-time fighter
pilot training, 3-D seismic/geologic oil exploration, and
pharmaceutical drug design using supercomputing
tightly coupled to high-performance 3-D workstations.
Previously, I had worked with Dr. Lumsden at Baylor
College of Medicine on a peripheral arterial disease
(PAD) multi-institutional clinical trial using 3T MRI
with specialized bilateral coils for measuring plaque
within the superficial femoral artery. Dr. Lumsden
would repeat the phrase “it’s all about the imaging”
like a mantra for the vascular residents and fellows. Dr.
Butler’s vision for an interactive, real-time, 3-D radiation
dose cloud for intensity modulated radiation therapy
(IMRT) treatment planning was a logical and parallel
extension of Dr. Lumsden’s vision.
However, Dr. Butler needed to have a full integration
of diagnostic imaging capabilities that would allow
for clearer visualization and provide a more accurate,
interactive tumor targeting and delineation system
that could protect normal tissue from adverse radiation
exposure. It was at this point that I decided to design
an FDA-approved clinical diagnostic imaging integration
that would be clinically relevant and make a
difference in patient care.
Why “Plato’s CAVE?”
When I asked Dr. Butler to think about a name for
this pilot clinical project, he responded with “Plato’s
CAvE” from Book vII of Plato’s The Republic, “The
Allegory of the Cave,” in which the prisoners see and
28 vII (1) 2011 | MDCvJ

Figure 4. Plato, in The Republic, Book VII, 514a-520a. 1 Figure 5. “The Anatomy Lecture of Dr. Nicolaes Tulp” by Rembrandt,
1632.
hear shadows and echoes cast by objects that they
cannot see clearly (Figure 4 and 5). 1
It was the perfect code name for exploring the art and
science of “seeing” the invisible.
Dr. Butler’s research over the past decade has been
focused on image-guided radiation and gene therapies
for cancer. In the past year, he and I have broadened the
focus to include visualization-guided clinical interventions
that are within the domain of surgical oncology,
including reconstructive surgery and transplantation.
This expanded focus was made possible by the development
of an N-dimensional (space, time, color, and
multimodality images) image-guided intervention
system, more correctly a visualization system, that has
been operational in our laboratory since April 2009.
Plato’s CAVE: The Advanced Clinical
Visualization Process
The current standard of care for medical imaging is
to interpret slices of 2-D shades-of-gray images in an
attempt to translate them into a physician’s “personal
virtual 3-D anatomical and disease world,” then interpreting
the problem and rendering a written diagnosis
— granted, an expert professional diagnosis by a welltrained
imaging specialist, but still an interpretation of
a 2-D dataset nonetheless. Plato’s CAvE raises the bar
with an advanced clinical visualization process that
creates 3-D images derived from a patient’s DICOM
image studies that have been pulled from Methodist’s
Picture Archiving and Communication System (PACS),
from other institutional PACS via electronic transfer, or
from CDs that patients bring with them. Regardless of
the image source, the 3-D visualizations are ready for
projection and viewing on a variety of screen formats
within minutes. The region of interest is measurable,
can be manipulated in three dimensions, and can be
presented stereoscopically like the movie Avatar. This
approach makes full use of the strengths of each imaging
modality by displaying and/or fusing all of the
images available for the patient (CT, MRI, PET and,
soon, HR ultrasound) in a sequence of the events that
are relevant to the treatment team. The scene is adaptable
to all surgical interventions, from reconstruction
through transplantation, and capable of bringing quality
improvements to the diagnosis and treatment
planning for many medical conditions.
Our technology is totally complementary to all
standard-of-care imaging modalities currently in use
and some that are in development, i.e., physiodynamic
processes, beating heart, mitral valves opening and
closing. There is a high level of clinical imaging and
medical device industry interest in experimenting with
or enhancing Plato’s CAvE with natural user interactions.
Our surgeons have discovered, once they work
with this system, that they cannot easily justify returning
to the current standard of viewing images for their
patients. We have designed and integrated the CAvE
to function as a node/portal on a physician grid or
network. It is not an island: the visualization can be
distributed to the scientist’s or clinician’s desktop
because it is server-based, thin-client enabled, and
HIPAA compliant.
The system offers enormous opportunity for educating
primary care and referring physicians, patients and
their families, medical students, residents and staff surgeons
by narrowing the degree of uncertainty that each
brings to the interaction (Figure 6 and 7). It also gives
the medical team the ability to make a more informed
decision regarding the best intervention or treatment
of the disease. In some cases, the visualization has
revealed previously unrecognized ancillary anatomical
findings or additional disease complications.
Development, testing, validation and translation of
this technology into practice will shape the metrics
MDCvJ | vII (1) 2011 29

Figure 6. Virtual surgical table inside Plato’s CAVE using TeraRecon,
Inc. visualization
necessary for adoption, and we anticipate that more
refined tools will be developed to interact with the
visualized patient. ultimately, the images that are
fused to create the visualized patient will be registered
and superimposed to the real patient, and the instruments
will interact with the patient to provide clinical
interventions of the highest quality and safety. At the
fundamental level, this system has universal applicability
across all medical specialties and subspecialties and
will allow the patient and physician to understand disease
processes in ways never before possible.
We plan systematic evaluations of organ systems
and their related disease processes. The hepatobiliary
system provides a good example of the importance of
doing this with high-fidelity visual data. Measuring the
volume of this difficult-to-image organ is key to clinical
decisions with respect to cancer diagnosis and therapy,
among other medical conditions. yet even simple volumetric
evaluation represents a paradigm shift in the
way that cancers are staged. For example, conventional
staging of liver cancer is based on two dimensions — X
and y. Typically “size,” as measured on axial CT or MRI
images, is a major consideration, e.g., a 5 cm lesion will
be classified as stage T2. In contrast, volumetric evaluation
introduces a third dimension, Z, and may change
the staging in significant ways. We now evaluate all
hepatobiliary tumors volumetrically and within the last
few weeks have begun mapping the arterial and venous
branches so that surgeons can clearly avoid them while
performing a resection.
Physician Response to Plato’s CAVE
Plato’s CAvE has generated a great deal of interest in
and respect for its current ability and potential capabilities
among our surgical colleagues. Some have used it
Figure 7. Virtual surgical table inside Plato’s CAVE using TeraRecon,
Inc. visualization.
multiple times to perform pre-surgery evaluation and
planning, even to the extent of revising initial treatment
plans or not doing an intervention based on the
Figure 8a. Virtual surgical table inside Plato’s CAVE standard-of-care
alongside interactive volume visualization.
Figure 8b. Volume visualization with red finger tracings on virtual
surgical table.
30 vII (1) 2011 | MDCvJ

Figure 9. The Artery of Adamkiewicz identified by Dr. Sam Henly.
Magnified virtual surgical table view inside Plato’s CAVE using
Siemens flash CT scan study with TeraRecon, Inc. visualization.
Figure 11. TeraRecon, Inc. visualization for planning the repair of
esophageal varices that was more complicated than anticipated.
additional information they gained from the 3-D visualization
(Figures 8a and 8b).
Some surgeons have used our visualization as an
education tool for their patients (Figures 9 and 10). The
surgeons are impressed with the quality of the visualization,
the ease and speed with which positions of the
images can be changed, the ability to strip away tissue
that blocks the view of the subject tissue, the fact that
no contrast agents are required to achieve the visualization,
the saving of time, and the unexpected ancillary
findings (Figures 11 and 12).
On the other hand, some surgeons have said they
do not see the need for such an environment because
their experience overrides the real-time process and 3-D
visualization that we provide, and that conventional
imaging meets their needs. yet, these same surgeons
admit that the CAvE would have great value for medi-
Figure 10. The Artery of Adamkiewicz, identified by Dr. Sam Henly,
on the virtual surgical table inside Plato’s CAVE using Siemens flash
CTA scan with TeraRecon, Inc. visualization.
Figure 12. Virtual surgical table view inside Plato’s CAVE using GE
CTA scan study with TeraRecon, Inc. visualization for planning repair
of esophageal varices.
cal education because of its clarity and responsiveness
for accurately viewing patient-specific images and associated
disease.
Clearly, N-dimensional visualization challenges
current clinical practice paradigms. unlike many
technological advances in science and medicine, the
constraint on acceptance and adoption of Plato’s CAvE
does not appear to be clinician resistance to change but
rather the hospital’s need for 1) metrics that will satisfy
institutional risk assessment requirements, and 2)
an effective process for disseminating the innovation
along with best practice standards and protocols that
are accepted by the general clinical staff. We routinely
ask surgeons, “When you review currently available
CT or MR studies for pre-surgical planning, have the
standard diagnostic imaging and viewing tools provided
you with the confidence that your treatment plan
MDCvJ | vII (1) 2011 31

Figure 13. Looking down on the 36 in x 42 in multi-user virtual surgical table in Plato’s CAVE using
Siemens flash low-dose CT scan patient data with TeraRecon, Inc.
is based on objective visual anatomical accuracy versus
subjective image estimation?” Their response is invariably
“No.”
In my 30 years within the scientific visualization
world, I believe the experience that Plato’s CAvE provides
is approaching what some would call a black
swan. The term “black swan” was a Latin term; its
oldest reference is in the poet Juvenal’s expression that
“a good person is as rare as a black swan” (“rara avis
in terris nigroque simillima cygno”). 2 It was a common
expression in 16th-century that derived from the oldworld
presumption that all swans must be white
because all historical records of swans reported that
they had white feathers. After the 1697 discovery of
black swans in Western Australia, 3 the term metamorphosed
to connote that a supposed impossibility may
later be found to exist. Writer Michael Mandel used
the term succinctly in an online issue of Bloomberg
Businessweek: “The world is consistently capable of generating
‘black swans’ — outlier events, which have an
extreme impact and retrospective (though not prospective)
predictability.” 4
For the last few months, the clinical focus of the
CAvE has evolved from physician-to-physician collaboration
to physician-to-patient consultation and
consensus. Almost 200 patients have been reviewed in
the CAvE, and a word-of-mouth, patient-driven referral
process has evolved because the involved physicians say
that Dr. Butler’s vision is providing an additional level
of confidence, trust and understanding in what the physician
and medical team can provide for each patient.
The Future of Plato’s CAVE
We have begun to develop, adapt and test dual-reality
tools (physical devices synched with a virtual clone
of the device) that enable operator interaction with the
patient-specific volume. Modeled to reflect the way
surgeons use the real device, these tools will allow measurement
and quantification of disease processes within
the visualized patient (e.g., volume of a liver or blood
vessel, size and location of an obstruction within the
bile duct, how a pancreatic carcinoma encases the superior
mesenteric artery, etc.). The physician can interact
with the visualization of the patient before performing
a procedure and record a scenario that can act as a
look-ahead avoidance system, something the current da
vinci robots do not permit (Figure 13). This interaction
will occur in numerous ways, one of which involves
using a flat-panel, multi-user, multi-touch “surgical
table” that allows multiple users to interact simultaneously
with the visualized patient in a 1:1 mapped
relationship. We are currently refining techniques for
capturing a surgeon’ s eye-hand movements in the OR
that will enable us to build feedback loops based on
32 vII (1) 2011 | MDCvJ

Figure 14. Reconstructed left breast with implant failure and disease
in right breast; CT from Siemens.
haptic, hand-gesture, voice, and eye-tracking interaction
between the operator and the patient visualization synchronously
as it appears on the surgical table.
The CAvE’s multi-dimensional interactive field of
view includes the three spatial dimensions as well
as motion, coordinated contrasting colors for different
tissue types (such as muscle, organ, bone, nerve,
blood vessels and ducts), time, and scale — in effect,
it provides a virtual biopsy of any part of the visualized
patient. Our first research and development project
will soon enable Plato’s CAvE to integrate and visualize
physiological and biochemical parameters at the cell
and molecular levels for breast cancer pattern finding
and refined surgical reconstruction (Figures 14 and 15).
Plato’s CAvE will be tailored for an array of clinical
practices, ranging from tumor board and surgical
Figure 15. Toshiba breast MRI images without contrast, volume
visualization on virtual surgical table. Please note clarity of IMAs.
Figure 16. Virtual surgical table, large screen and iPad. Figure 17. iPad and iPhone with transplanted kidney running
remotely from area code (650).
review processes within a hospital or department to
surgeons’ workstations linked to a high-performance
computing cloud for new device development.
If Plato’s CAvE is enabled to provide full support for
physicians within The Methodist Hospital System, with
the goal of using advanced clinical visualization techniques
that integrate results of the patient’s EMR with
global bioinformatic markers, then the secondary goal
of using CAvE software techniques that reflect timesaving
workflow templates for individual physicians
will provide an enterprise system that offers increasing
levels of interactivity, speed and accuracy. It will
also provide many opportunities, with our worldwide
partners, to explore international clinical practice, translational
research, and medical education with greater
specificity for local environments.
MDCvJ | vII (1) 2011 33

We are currently using devices such as the iPhone
and iPad with our surgeons and hope to include all
physicians and medical students in a gradual, systematic,
open-source process of sharing anatomic
atlases and summaries of current specialized imaging
protocols wherever they may be (Figure 16 and
17). Dual-reality visualizing (DRv) of patients can
become a part of this open-source knowledge base as
Plato’s CAvE technology is developed, clinically vetted,
released and able to record a visual record of surgical
procedures.
Lessons being learned in Plato’s CAvE are validating
the clinical practicality of blending imaging, visualization
and simulation with a CAvE measurement system
that, with a dual-reality instrument or probe, offers six
degrees of freedom within the virtual patient. What
started with Dr. Lumsden’s and Dr. Butler’s mandate to
“give me all of the imaging” is evolving into “calibrate,
measure and record everything within a surgeon-specified
360-degree field of view” and providing a more
accurate, patient-specific, pre-surgical planning and
visualization-guided surveillance system (Figures 18a
and 18b).
Conclusion
Plato’s CAvE was built in 90 days and operational
on April 1, 2009. Every day, it is refining an advanced
clinical visualization acquisition process for viewing
patient-specific, standard-of-care images within a multidimensional
computer-augmented virtual environment.
Its FDA-cleared technology is enhancing image acquisition
protocols, diagnostic accuracy, treatment planning,
post-treatment evaluation and follow-up while increasing
patient safety and education, improving clinical
productivity, and reducing costs.
Dr. Butler’s vision of multiple physicians collaborating
in a dedicated space and viewing all of the relevant
diagnostic images on a large screen has been realized.
Plato’s CAvE has made and will continue to make
a quality difference in patient care at The Methodist
Hospital and soon will be deployed as a pre-surgical
planning clinical imperative. As one young surgeon said,
“It is the difference between knowing and guessing.”
Figure 18a and b. Real-time 3-D virtual surgical table inside Plato’s
CAVE; patient study courtesy of OSIRIX with TeraRecon, Inc.
reconstruction and 3-D visualization.
References
1. Sir Luke Fildes: The Doctor 1887, oil on canvas. Br J Gen
Pract. 2008 March 1;58(548):210–213.
2. The Allegory of the Cave. In: Plato. The Republic, Book
vII, 514a-517a. 360 B.C.E.
3. Halsall P. Internet Ancient History Sourcebook [Internet].
New york: Fordham university; c1998-2010. Juvenal: Satire
vI. 1999 Jan [cited 2010 Nov 15]. Available from: http://
www.fordham.edu/halsall/ancient/juvenal-satvi.html.
4. The Constitutional Centre of Western Australia [Internet].
Australia: Government of Western Australia; 2008 May 27
[cited 2010 Nov 15]. Available from: http://www.ccentre.
wa.gov.au/index.cfm?event=heritageIconsJanuary.
5. Mandel M. The Reverse Black Swan, Part I. Bloomberg
Businessweek [Internet]. 2010 Apr 1 [cited 2010 Nov 2].
Available from: www.businessweek.com/the_thread/
economicsunbound/archives/2009/04/the_reverse_bla.
html.
34 vII (1) 2011 | MDCvJ

M.E. Bertrand, M.D.
Introduction
WHAT ARE THE CuRRENT RISKS OF
CARDIAC CATHETERIZATION?
Michel E. Bertrand, M.D.
Lille Heart Institute, Lille, France
Since the first heart catheterization performed by Werner Forssmann on himself in 1929, this technique
has undergone an extraordinary expansion and widespread application. Today, several million heart catheterizations
are performed throughout the world each year. Heart catheterization is not only a fantastic
investigative tool that provides precise information regarding anatomy and physiology, but it also offers
a number of important and very effective interventions. Forssmann imagined heart catheterization as a
delivery mechanism for drugs to enhance their efficacy, and heart catheterization has indeed become, in
a large number of cases, a therapeutic tool.
Cardiac catheterizations are performed in a large number of centers worldwide, and the complication rate
is low. Nevertheless, zero risk does not exist in medicine. This analysis focuses on the procedural risks
of cardiac catheterization and coronary angiography but does not discuss the risks related to specific
interventions (e.g., the risks of stent implantation, atherectomy, or systemic anaphylactoid reactions to
iodinated contrast media). Actually, vital risks of heart catheterization are very rare, and most complications
are related to the access site.
Recent Data Concerning the Risks of
Procedure-Related Complications
Many publications and books about complications
during and after cardiac catheterization refer to the
publication of a 1991 report prepared by Noto for the
Society for Cardiac Angiography and Interventions. 1
Ten years later, a single-center report, summarized in
Table 1, was published by the Montreal Heart Institute. 2
The report is a prospective analysis collected over a
2-year period (April 1996 to March 1998) of 11,821
procedures and includes in-hospital and one-month
follow-up of 7,953 diagnostic and 3,868 therapeutic
procedures.
More recent data can be obtained from the ALKK
registry (Arbeitsgemeinshaft Leitende Kardiologische
Krakenhausärzte) initiated in 1992 in Germany. The
last report, published in 2005, 3 covers the year 2003 and
89,064 procedures performed in 75 German centers,
including 58,935 invasive procedures, 23,867 invasive
Complication Diagnostic Therapeutic Total
n=7,953 n=3,868 n=11,821
Death 34 (0.4%) 42 (1.1%) 76 (0.6%)
Procedure-
related death
8 (0.1%) 21 (0.5%) 29 (0.2%)
Q-wave MI 3 (0.04%) 24 (0.6%) 27 (0.2%)
Non-Q-wave MI 5 (0.06%) 133 (3.4%) 138 (1.2%)
Emergency
CABG
Pulmonary
edema
4 (0.05%) 13 (0.3%) 17 (0.1%)
11 (0.1%) 21 (0.5%) 32 (0.3%)
Table 1. Incidence of cardiac complications from a single center
reporting 11,821 procedures (April 1996-March 1998). 2
MDCvJ | vII (1) 2011 35

Complications Total Stable
angina
In-hospital
death
In cath-lab
death
Myocardial
infarction
procedures followed by PCI, and 6,802 lone PCIs. A
summary of this registry is presented in Table 2.
Two years ago, Mehta et al. published the rate of
complications occurring in 11,703 pediatric cardiac catheterization:
the rate was 7.3% of cases with a mortality
risk of 0.23%. 4
Major Vital Complications
Unstable
angina
NSTEMI STEMI
0.45% 0.21% 0.48% 1.74% 2.84%
0.02% 0.01% 0% 0.03% 0.30%
0.10% 0.08% 0.26% 0.25% 0.34%
TIA/stroke 0.11% 0.01% 0.17% 0.25% 0.05%
CPR 0.16% 0.10% 0.30% 0.43% 0.87%
Pulmonary
embolism
0.01% 0% 0.10% 0% 0%
Table 2. Mortality and procedure-related complications in a cohort of 57,581
patients with coronary artery disease and lone diagnostic procedures (ALKK
registry). 3
The overall risk of death from heart catheterization
is less than 0.5%, and only 0.02% occur in the catheterization
laboratory. Death may be caused by perforation
of the heart (extremely rare) or great vessels, cardiac
arrhythmias, myocardial infarction, or systemic anaphylactic
reactions to iodinated contrast media (1 death
per 55,000). The risk of in-hospital death is significantly
higher when catheterization is performed in the presence
of acute coronary syndrome (2.84% in patients
with ST elevation myocardial infarction) than when it is
performed in stable patients (0.21%).
The risk of myocardial infarction (MI) is 1 per 1,000
patients (0.1%). However, these figures are certainly
higher after coronary interventions, especially with
the new definitions based upon elevation of troponin
levels. Several studies have investigated the relationship
between a rise in periprocedural levels, indicating myonecrosis,
and the clinical outcome; an increase of more
than three times the upper limit of normal for creatine
kinase-MB has a significant clinical impact, and this
cut-off is routinely used in many clinical trials concerning
percutaneous coronary interventions.
Large MI are caused by catheter-induced coronary
injury or embolization from the catheter or left
ventricular (Lv) thrombus. The most common site of
catheter-induced injury is the ostium of the coronary
vessel with occlusive dissection. Coronary
embolization usually occurs when catheters are
insufficiently rinsed, allowing a thrombus to be
pushed into the vessel and leading to infarction
and, even more likely, to cardiac arrest when the
thrombus is expelled into the left main. Small
air emboli are usually benign but may create
ischemia for 5-10 minutes.
The rate of cerebrovascular accidents ranges
from 0.11 to 0.4%. 5-7 Major cerebrovascular accidents
with permanent disabling disorders have
been noted but with a very low incidence. In
most cases, these cerebral ischemic events are
transient and without sequel. Several reports 8,9
have mentioned the high incidence of microemboli
during left heart catheterization, the
majority of which are probably of gaseous origin
since they occurred predominantly during contrast
media injection in this study. With the advent of diffusion-weighted
MRI (DW-MRI), which is particularly
sensitive in detecting acute ischemic lesion, 10 it has been
shown that the rate of asymptomatic cerebral emboli
might be much more frequent. Omran 11 observed that
silent cerebral embolism after retrograde catheterization
of the aortic valve in valvular aortic stenosis was present
in 22% of cases, and Lund 12 and Busing 13 found an
incidence of 13.5% and 15%, respectively. More recently,
Hamon et al., 10 using DW-MRI, found an incidence of
only 2.2% in patients with severe aortic valve stenosis.
Serious, life-threatening arrhythmias are observed
mainly during coronary angiography (0.5%). They were
noted in the past when the large coronary catheters
(>8F) were used, particularly during intubation of the
right coronary artery. They generally occurred when
the anatomical configuration of the first segment of the
right coronary artery allowed untimely deep intubation
and suppression of the flow by the wedged catheter.
The resulting arrhythmia was most often a ventricular
fibrillation, easily reducible by electrical defibrillation.
In some other cases, it was an A-v block, which sometimes
required a temporary pacing. These complications
have become less frequent with the use of smaller
catheters (5–6F).
ventricular tachycardia is most likely to occur when
introducing a catheter (most often a pigtail catheter)
in the left ventricle and mainly in patients with Lv
dysfunction or Lv aneurysm. Atrial fibrillation and
supraventricular tachycardia might be observed when
the catheter is introduced in the left atrium through an
atrial septal defect or patent foramen ovale.
36 vII (1) 2011 | MDCvJ

Vascular Access Complications
A number of local vascular complications have been
described and are observed in 0.5 to 1.5% of patients,
although these complications are probably underreported.
They occur after left heart catheterization and
arterial access.
Perforation of peripheral arteries by a guide wire or
a catheter is uncommon but may occur in cases of very
tortuous vessels and when stiff wires and catheters are
used. A retroperitoneal hemorrhage can occur with or
without hemodynamic compromise. The use of a J-type
tip prevents this rare complication.
Artery dissection is more frequent with stiff guide
wires, but fortunately the flap is created against the
flow of blood (from distal to proximal), and in most the
cases the flap is sealed. However, dissection may promote
local thrombosis and artery occlusion.
Arterial occlusion is rare. It can be observed when
the femoral artery puncture is done exactly at the site of
an atherosclerotic plaque. This “iatrogenic” plaque rupture
may lead to thrombosis in situ and occurrence of
acute leg ischemia. In most cases, this peripheral acute
leg ischemia is related to a distal embolism of a plaque
or a fragment of plaque dislodged during the passage of
the catheter in an atherosclerotic iliac artery. This complication
requires rapid embolectomy with the Fogarty’s
catheter.
Pseudoaneurysm is an intraparietal artery hematoma
14 characterized by swelling at the puncture site
and a murmur at auscultation. Initially, surgical repair
was recommended, but ultrasound-guided compression
therapy (uGCT) is currently the nonsurgical recommended
treatment. 15 Routine color duplex control of
the puncture site the day following the removal of the
sheath after percutaneous catheterization and uGCT
increases the success rate of uGCT and minimizes the
need for surgical repair. 14 Infection may occur at the site
of pseudoaneurysm. 16
Arteriovenous (Av) fistula occurred at a rate ranging
from 0.017% in 1989 to 0.86% in 2002. 17, 18 In most cases,
the fistulas are located below the bifurcation of the
common femoral artery. Actually, the common femoral
artery and the common femoral vein are located side by
side, but after the bifurcation, the proximal femoral vein
crosses the proximal superficial femoral artery laterally
and lies posterior to the artery. Thus, a puncture at that
site might interest both vessels, and this facilitates the
connection. Between 30-38% of iatrogenic Av fistulas
close spontaneously within one year. Cardiac volume
overload leading to heart failure and limb damage is
highly unlikely, so, in general, conservative management
for at least one year is justified.
Numerous closure devices have been developed
in recent years to obtain an efficient arteriotomy closure
immediately at the end of the procedure. For the
moment, evidence-based data are disappointing, and
all randomized studies included in a recently published
meta-analysis 8 confirmed that, compared to manual
management of the puncture site, these devices are
unable to reduce complications; moreover, they sometimes
induce additional complications such as infection
or ischemia.
Retroperitoneal hemorrhage requires a specific
mention because it can affect the vital prognosis of the
patient, and early recognition is especially critical. The
clinical signs derived from the retrospective study of
Farouque et al. are listed in Table 3. 19
Symptoms
Abdominal pain 42%
Groin pain 46%
Back pain 23%
Diaphoresis 58%
Physical signs
Abdominal tenderness 69%
External groin hematoma 31%
Bradycardia 31%
Hypotension 92%
Table 3. Summary of clinical signs for retroperitoneal hemorrhage
diagnosis (n=26 patients; incidence of 0.74%, adapted from
Farouque et al. 19 ).
Different mechanisms can lead to major bleeds,
which represent an important complication after left
heart catheterization. Within the last 10 years, diagnostic
or therapeutic cardiac catheterizations have been
performed in patients who received a combination of
very powerful antithrombotic drugs. Large groin hematomas
and retroperitoneal hemorrhage, which occur
with the femoral approach, are associated with important
blood loss that requires blood transfusion. These
complications and related transfusions have been identified
as a predictor of poor outcome. The transradial
approach is associated with fewer bleeding events and
transfusions than is the femoral approach. A meta-analysis
of 15 randomized clinical trials (including 3,662
patients) 20 showed that in terms of major adverse cardiovascular
events (death, MI, stroke, emergency PCI or
CABG), both the radial and femoral approach yielded
MDCvJ | vII (1) 2011 37

similar results, with 2.3% and 2.6% of events respectively.
The radial approach was significantly superior
in the risk of entry site complications (0.3% versus 2.8%;
odds ratio: 2.2, 95% confidence interval, 0.11–0.44) but
at the price of a higher rate of procedural failure (odds
ratio 3.45, 95% confidence interval, 1.63–6.71; p 75 years, female gender or obesity, and renal
insufficiency or a prior history of bleeding represent the
major predictive factors of complications.
References
1. Noto TJ Jr, Johnson LW, Krone R, Weaver WF, Clark DA,
Kramer JR Jr, vetrovec GW. Cardiac catheterization 1990: a
report of the Registry of the Society for Cardiac Angiography
and Interventions (SCA&I). Cathet Cardiovasc Diagn.
1991 Oct;24(2):75-83.
2. Chandrasekar B, Doucet S, Bilodeau L, Crepeau J, deGuise
P, Gregoire J, Gallo R, Cote G, Bonan R, Joyal M, Gosselin
G, Tanguay JF, Dyrda I, Bois M, Pasternac A. Complications
of cardiac catheterization in the current era: a
single-center experience. Catheter Cardiovasc Interv. 2001
Mar;52(3):289-95.
3. Zeymer u, Zahn R, Hochadel M, Bonzel T, Weber M,
Gottwik M, Tebbe u, Senges J. Incications and complications
of invasive diagnostic procedures and percutaneous
coronary interventions in the year 2003. Results of the
quality control registry of the Arbeitsgemeinschaft
Leitende Kardiologische Krankenhausarzte (ALKK).
Z Kardiol. 2005 Jun;94(6):392-8.
4. Mehta R, Lee KJ, Chaturvedi R, Benson L. Complications
of pediatric cardiac catheterization: a review in the current
era. Catheter Cardiovasc Interv. 2008 Aug 1;72(2):278-85.
5. Brown DL, Topol EJ. Stroke complicating percutaneous
coronary revascularization. Am J Cardiol. 1993 Nov
15;72(15):1207-9.
38 vII (1) 2011 | MDCvJ

6. Segal AZ, Abernethy WB, Palacios IF, BeLue R, Rordorf
G. Stroke as a complication of cardiac catheterization:
risk factors and clinical features. Neurology. 2001 Apr
10;56(7):975-7.
7. Wong SC, Minutello R, Hong MK. Neurological complications
following percutaneous coronary interventions (a
report from the 2000-2001 New york State Angioplasty
Registry). Am J Cardiol. 2005 Nov 1;96(9):1248-50.
8. Bladin CF, Bingham L, Grigg L, yapanis AG, Gerraty R,
Davis SM. Transcranial Doppler detection of microemboli
during percutaneous transluminal coronary angioplasty.
Stroke. 1998 Nov;29(11):2367-70.
9. Leclercq F, Kassnasrallah S, Cesari JB, Blard JM, Macia JC,
Messner-Pellenc P, Mariottini CJ, Grolleau-Raoux R. Transcranial
Doppler detection of cerebral microemboli during
left heart catheterization. Cerebrovasc Dis. 2001;12(1):59-65.
10. Hamon M, Gomes S, Oppenheim C, Morello R, Sabatier
R, Lognoné T, Grollier G, Courtheoux P, Hamon M.
Cerebral microembolism during cardiac catheterization
and risk of acute brain injury: a prospective diffusionweighted
magnetic resonance imaging study. Stroke. 2006
Aug;37(8):2035-8. Epub 2006 Jun 22.
11. Omran H, Schmidt H, Hackenbroch M, Illien S, Bernhardt
P, von der Recke G, Fimmers R, Flacke S, Layer G, Pohl C,
Lüderitz B, Schild H, Sommer T. Silent and apparent cerebral
embolism after retrograde catheterisation of the aortic
valve in valvular stenosis: a prospective, randomised
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12. Lund C, Nes RB, ugelstad TP, Due-Tønnessen P, Andersen
R, Hol PK, Brucher R, Russell D. Cerebral emboli during
left heart catheterization may cause acute brain injury. Eur
Heart J. 2005 Jul;26(13):1269-75. Epub 2005 Feb 16.
13. Büsing KA, Schulte-Sasse C, Flüchter S, Süselbeck T,
Haase KK, Neff W, Hirsch JG, Borggrefe M, Düber C.
Cerebral infarction: incidence and risk factors after
diagnostic and interventional cardiac catheterization —
prospective evaluation at diffusion-weighted MR imaging.
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14. Wery D, Delcour C, Jacquemin C, Richoz B, Struyven J.
[Iatrogenic femoral pseudo-aneurysm. Analysis of the
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15. Loftus WK, Isaacs JL, Spyropoulos P. Femoral artery
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16. McCready RA, Siderys H, Pittman JN, Herod GT,
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18. Kelm M, Perings SM, Jax T, Lauer T, Schoebel FC, Heintzen
MP, Perings C, Strauer BE. Incidence and clinical
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19. Farouque HM, Tremmel JA, Raissi Shabari F, Aggarwal
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MDCvJ | vII (1) 2011 39

M. Loebe, M.D.
Introduction
INITIAL CLINICAL EXPERIENCE OF TOTAL
CARDIAC REPLACEMENT WITH DuAL
HEARTMATE-II ®
AXIAL FLOW PuMPS FOR
SEvERE BIvENTRICuLAR HEART FAILuRE
Matthias Loebe, M.D., Ph.D. a ; Brian Bruckner, M.D. a ; Michael J. Reardon,
M.D. a ; Erika van Doorn, M.D. a ; Jerry Estep, M.D. a ; Igor Gregoric, M.D. a ;
Faisel Masud, M.D. a ; William Cohn, M.D. b ; Tadashi Motomura, M.D., Ph.D. a ,
Guillermo Torre-Amione, M.D. a ; O.H. Frazier, M.D. b
a Methodist DeBakey Heart & Vascular Center, and b Texas Heart Institute, Houston, Texas
Continuous flow pumps are commonly used to support patients with acute cardiogenic shock and are
increasingly used for chronic support in heart failure patients. In the past, pulsatile long-term left ventricular
assist devices (LVADs), such as the Novacor and HeartMate-I, provided adequate cardiac support
yet they were subject to complications including eventual device failure and infections. With improvements
in technology and migration towards axial or continuous flow devices, device miniaturization has
become possible, thereby leading to improved anatomical fitting, less vibration and driving noise, and
more efficient power consumption. Furthermore, device durability, anti-thrombogenicity, and physiological
adaptation to continuous flow pumps appear to be clinically feasible not only for bridge-to-transplant but
1, 2
also for extended longer-term support, namely “destination therapy.”
In cases of severe biventricular heart failure, right heart support may be required in addition to left heart
support. Using a biventricular assist device (BiVAD) to treat biventricular heart failure is one reasonable
option; 3 however, its clinical feasibility remains controversial. 4 Another acceptable option for treating
biventricular heart failure is total cardiac replacement with a total artificial heart (TAH). 5 According to
clinical results reported by the INTERMACS Study group, the Syncardia pulsatile TAH (Syncardia
Systems, Inc., Tucson, AZ, USA) whose implantation resulted in lower postoperative complications and
better bridge-to-transplant rates compared to conventional BiVAD implants. 6
As a similar technology transition from pulsatile to nonpulsatile LVAD, nonpulsatile mechanical circulatory
support may be applicable for total cardiac replacement as well, i.e., continuous flow TAH. Unlike
the conventional pulsatile TAH driven by pneumatic compression, a continuous flow total artificial heart
(CFTAH) would generate absolutely no pulsatility at all. To bring CFTAH into the clinical arena, flow control
including the right and left flow balance, inflow suction prevention, and overall physiological adaptation
are still remaining issues to be solved. 7 Dr. O.H. Frazier (Texas Heart Institute, Houston, TX) reported
the first animal study experiences using a CFTAH implant as a total heart replacement — with two
HeartMate II ® axial flow LVADs — in 2009, which followed a study using dual Jarvik 2000 pumps
in 2005. 8, 9 The animals implanted with the CFTAH in these studies maintained normal physiological
parameters for up to seven weeks following device implant. These earlier results were encouraging and
suggested the potential future role of a CFTAH for treating biventricular heart failure.
This case report describes our initial clinical experience of total cardiac replacement (complete resection
of the heart) with dual HeartMate II ® (HM II) axial flow pumps (Thoratec Corporation, Pleasanton, CA,
USA) for treating severe biventricular heart failure.
40 vII (1) 2011 | MDCvJ

Case Report
Clinical course
The patient was a 25-year-old male, originally diagnosed
with nonischemic dilated cardiomyopathy,
and was 4-year status post orthotopic heart transplant
following chronic HM II LvAD support. 10 He
was the first patient supported with the HM II, which
is currently the most widely used LvAD. He had the
pump implanted at the Texas Heart Institute at St.
Luke’s Episcopal Hospital in Houston by Dr. Frazier
in November 2003 and was supported for 749 days.
Following his heart transplant, the patient developed
end-stage renal disease and was maintained on chronic
hemodialysis in addition to chronic LvAD support.
He was electively admitted for dialysis access surgery,
during which he suddenly developed cardiogenic shock
with cardiac arrest during the operative procedure.
He was urgently resuscitated and placed on femoral
arteriovenous extracorporeal membrane oxygenation
(ECMO) support. Transthoracic echocardiogram
showed severely impaired biventricular function with
ejection fraction less than 10%. Over the next 24 hours,
he continued to be stabilized on full ECMO support and
mechanical ventilation. The patient’s general condition,
along with his hemodynamic parameters, gradually
improved on ECMO support, however profound biventricular
heart failure and multi-organ dysfunction
remained as life-threatening conditions. His case was
discussed at the transplant review board, and he was
deemed to be too high-risk for urgent heart transplant;
therefore, further mechanical support options were proposed.
After discussions with the Institutional Review
Board at The Methodist Hospital, the use of dual HM II
devices was granted as a compassionate application for
severe biventricular heart failure status post-orthotopic
heart transplantation in this critically ill patient.
Intra-operative findings and surgical procedures
On May 3, 2010, the patient was taken to the operating
room; upon entering the chest by redo sternotomy,
there were noted to be numerous adhesions around the
right ventricle. The ascending aorta was not recognizable
and dense adhesions also surrounded it. During
the dissection, a short period of hypothermic circulatory
arrest (femoral cannulation) was performed to
control surgical bleeding. The heart was observed to be
diffusely enlarged and exhibited signs of severe biventricular
failure. The cardiac tissue was extremely friable
and the ventricular tissue would have not held any
suture material. Therefore, both ventricles were completely
excised and two HM II axial flow pumps were
placed in order to achieve full hemodynamic support
as a total cardiac replacement therapy. Both ventricles
were excised and the atrial cuffs were then trimmed
in order to prepare them for anastomosis (Figure 1).
Prior to sewing ring and pump placement, two 20-mm
Hemashield grafts (MAQuET, Inc., Wayne, NJ, uSA)
were anastomosed to the pulmonary artery and the
ascending aorta using a 5-0 Prolene running suture
(Figure 2). Next, the left atrial cuff was then “buttressed”
to the sewing ring by using interrupted 2-0
Ti-Cron pledgeted sutures (Figure 3). Following the
left sewing ring placement, another sewing ring was
secured to a 38-mm Hemashield graft extension that
had also been sewn to the right atrial cuff (Figure 4).
To avoid collapse of the right inflow graft chamber
by possible inflow suction, BioGlue ® surgical adhesive
(CryoLife, Inc., Kennesaw, GA, uSA) was used by
applying it to the outside walls of the Hemashield graft.
The previously placed vascular graft “extensions” to
the aorta and pulmonary artery were then sewn to the
16-mm right and left pump outflow grafts included in
the HM II LvAD package. Finally, the inflow cannulas
for the HM II pumps were positioned into each sewing
ring, and the previously placed outflow grafts were
attached (Figure 5). Final orientation of both pumps is
depicted in Figures 6 and 7. The patient tolerated weaning
from cardiopulmonary bypass, and both pumps
Figure 1. Schematic of the heart resection and atrial trimming for
sewing ring placement. CPB was established by using the femoral
ECMO venous cannula with another cannula directly inserted into the
SVC through the right atrium. The previously placed femoral arterial
cannula was used as the arterial return for the bypass circuit.
MDCvJ | vII (1) 2011 41

Figure 2. Schematic of vascular graft “extensions” and preparation
for the left atrial sewing ring attachment. 20-mm vascular grafts were
sewn end-to-end and anastomosed to the ascending aorta and the
pulmonary artery. Ti-Cron sutures with pledgets were placed around the
circumference of the left atrial cuff.
Figure 4. Surgical view of the reconstructed right atrium and
HeartMate II ® placement for the right heart. A 38-mm vascular
graft was sewn to the right atrial cuff and the other graft end was
anastomosed to the sewing ring. The inflow conduit of the HeartMate
II ® axial flow pump was inserted into the sewing ring and secured
with tie bands..
Figure 3. Schematic of the atrial sewing ring positions. The left inflow
sewing ring was directly sewn to the left atrial cuff. A 38-mm vascular
graft was interposed between the right inflow sewing ring and the right
atrium to form a reservoir for venous return (neo-atrium).
Figure 5. Schematic of the dual HeartMate II ® axial flow pump
placement for total cardiac replacement. Two pumps were placed in the
mediastinum and each outflow graft was sewn to the ascending aorta
and pulmonary artery as previously described.
42 vII (1) 2011 | MDCvJ

Figure 6. Surgical view of dual HeartMateII® axial flow pump
placement. The outflow graft of the right pump and the inflow conduit of
the left pump are hidden behind the chest retractor.
were allowed to flow while the outflow grafts were
needle de-aired. The LvAD was eventually run at 9,200
rpm while the RvAD was run at 8,000 rpm. The initial
flows were estimated by the device as 3.5 L/min on the
right and 4.2 L/min on the left. During the rpm adjustment
of the pumps in the operating room, it was noted
that the RvAD had a tendency to “suction down” and
partially collapse the right atrium/graft when the rpm
was increased above 8,600 rpm. Therefore, the RvAD
was only allowed to function at the lowest rpm settings
(8,000-8,600) for the remainder of the patient’s support.
Postoperative clinical course
After several trips back to the operating room for
bleeding, the patient’s hemodynamic parameters stabilized
by post-op day 2. The LvAD was maintained at
9,200–9,400 rpm and RvAD flow was limited to 8,000–
8,600 rpm, which resulted in estimated flows of 4.8 L/
min on the left and 3.8 L/min on the right. The mean
arterial pressure was maintained around 70 mm Hg,
and the patient’s end organ function slowly improved
(i.e., improvement in liver function tests, arterial blood
gas). Also of significance, the patient’s pulmonary func-
Figure 7. Chest X-ray (A-P view) after total cardiac replacement with
Dual HeartMate II ® devices.
tion remained stable throughout the duration of his
support with normal blood gases and oxygen requirement
of 40–50% on the ventilator. Serial chest X-rays
also demonstrated clear lung fields without evidence of
congestion or infiltrate (Figure 7).
Despite eventual hemodynamic stabilization, the
patient developed severe brain injury and never
regained consciousness, most likely secondary to his
previous cardiac arrests. After one week of support
with the dual HM II pumps, the patient was withdrawn
from support because of irreversible neurologic injury.
An autopsy was performed and confirmed the diffuse
cerebral edema and brain injury. The pumps and outflow
grafts were also analyzed and revealed no
evidence of thrombus or any kinking of the grafts.
Discussion
The HM II axial flow LvAD is a FDA-approved continuous
flow (nonpulsatile) mechanical circulatory
assist device primarily designed for left ventricular
assistance in classical bridge-to-heart transplant 10 and
was also approved for destination therapy. In this case,
our patient had severe biventricular heart failure and
was dependent on ECMO support and high doses of
vasopressors. Following placement of the devices, the
vasopressor drips were weaned, liver tests improved,
and pulmonary function remained stable. All aspects
which indicate recovery of end organ function. This
patient had total bilirubin levels over 40 mg/dL prior to
MDCvJ | vII (1) 2011 43

cardiac replacement, but following biventricular replacement,
the total bilirubin levels fell to 13.1 mg/dL within
48 hrs of surgery.
One of the major issues we had was determining
the optimal rpm for each pump, especially on the right
side. As mentioned before, the HM II displayed flows
are only an estimated flow and can be unreliable, especially
in a dual configuration. During the implantation
surgery, as previously described, we were very careful
with the right-sided flows or the remaining right atrial
cuff and Hemashield graft (neo-atrium) would partially
collapse secondary to “suction” from the pump.
This tendency for the right side to collapse was another
problem we encountered during the initial operation;
however, strictly keeping the rpm on the RvAD at a
lower level and reinforcing the graft wall with Bioglue
appeared to correct this problem, because the dual HM
IIs did provide adequate hemodynamic support for
almost eight days. Additional caution was maintained
with RvAD flows due to concern over the possibility of
pulmonary congestion from high continuous flows and
potential alveolar damage; however, as previously mentioned,
the arterial blood gases remained within normal
limits. It would appear that continuous flow on the
right side was well tolerated by this patient and most
likely directly affected the left-sided flows as well. From
Fraizer’s experience with total cardiac replacement in
calves, right-sided continuous flow support was well
tolerated and in essence controlled the left-sided flows
independent of the actual pump rpms. 8 These
earlier studies and the current experience with our
patient suggest that dual continuous flow pumps provide
adequate and even “physiologic” support and
automatically respond (by increasing or decreasing
blood flow) to alterations in preload and afterload. In
conclusion, the dual HM IIs did provide a continuous
flow biventricular replacement strategy in this critically
ill patient. Further refinements of this dual pump configuration,
including optimization of the atrial cuffs,
and determination of the optimal right-sided flows will
be necessary before larger numbers of patients can be
implanted in the setting of a clinical trial.
References
1. Kamdar F, Boyle A, Liao K, Colvin-adams M, Joyce L,
John R. Effects of centrifugal, axial, and pulsatile left
ventricular assist device support on end-organ function
in heart failure patients. J Heart Lung Transplant. 2009
Apr;28(4):352-9.
2. Lahpor J, Khaghani A, Hetzer R, Pavie A, Friedrich I,
Sander K, Strüber M. European results with a continuousflow
ventricular assist device for advanced heart-failure
patients. Eur J Cardiothorac Surg. 2010 Feb;37(2):357-61.
Epub 1009 Jul 18.
3. El-Banayosy A, Arusoglu L, Morshuis M, Kizner L, Tenderich
G, Sarnowski P, Milting H, Koerfer R. CardioWest
total artificial heart: Bad Oeynhausen experience. Ann
Thorac Surg. 2005 Aug;80(2):548-52.
4. Holman WL, Kormos RL, Naftel DC, Miller MA, Pagani
FD, Blume E, Cleeton T, Koenig SC, Edwards L, Kirkin
JK. Predictors of death and transplant in patients with a
mechanical circulatory support device: a multi-institutional
study. J Heart Lung Transplant. 2009 Jan;28(1):44-50.
Epub 2008 Dec 12.
5. Copeland JG, Smith RG, Arabia FA, Nolan PE, Sethi GK,
Tsau PH, McClellan D, Slepian MJ, CardioWest Total Artificial
Heart Investigators. Cardiac replacement with a total
artificial heart as a bridge to transplantation. N Engl J
Med. 2004 Aug 26;351(9):859-67.
6. Stevenson LW, Pagani FD, young JB, Jessup M, Miller L,
Kormos RL, Naftel DC, ulisney K, Desvigne-Nickens
P, Kirklin JK. INTERMACS profiles of advanced heart
failure: the current picture. J Heart Lung Transplant. 2009
Jun;28(6):535-41.
7. Myers TJ, Robertson K, Pool T, Shah N, Gregoric I, Frazier
OH. Continuous flow pumps and total artificial hearts:
management issues. Ann Thorac Surg. 2003 Jun;75(6
Suppl):S79-85.
8. Frazier OH, Tuzun E, Cohn WE, Conger JL, Kadipasaoglu
KA. Total heart replacement using dual intracorporeal
continuous-flow pumps in a chronic bovine model: a
feasibility study. ASAIO J. 2006 Mar-Apr;52(2):145-9.
9. Frazier OH, Cohn WE, Tuzun E, Winkler JA, Gregoric ID.
Continuous-flow total artificial heart supports long-term
survival of a calf. Tex Heart Inst J. 2009;36(6):568-74.
10. Frazier OH, Delgado RM 3rd, Kar B, Patel v, Gregoric ID,
Myers TJ. First clinical use of the redesigned HeartMate
II left ventricular assist system in the united States: a case
report. Tex Heart Inst J. 2004;31(2):157-9.
44 vII (1) 2011 | MDCvJ

A.B. Lumsden, M.D.
Introduction
PuMPS AND PIPES
Alan B. Lumsden, M.D.; Stephen R. Igo, B.Sc.
Methodist DeBakey Heart & Vascular Center, Houston, Texas
“The solution to our problems most likely lie in someone else’s toolbox.
The challenge is in finding it.”
A significant problem in medical technology development, and perhaps the energy business, is that
developers are very in-bred — often exposed only to like-minded individuals, which in turn can prevent
innovation and maturation of “out-of-the-box” ideas. We believe that great benefit may be gained by
exposing cardiovascular and imaging researchers to technology currently available in the oil and gas world.
Thus was created the “Pumps and Pipes” symposium, a collaboration between Houston’s two most
prominent industries. Pumps and Pipes is a problem-focused forum analyzing issues relevant to both the
energy and medical worlds. The goal is to stimulate discussion, spark ideas and brainstorm with industry
counterparts to explore complementary technologies using common language and terminology, with such
themes as “Docs and Rocks,” “The Other Guy’s Toolkit,” and “Better Together, and “No Boundaries.”
Background
Cardiovascular medicine and the oil and gas industry
share remarkable similarities. Both deal in the business
of “pumps and pipes.” Both use imaging to identify
targets, navigate hollow tubes into those targets, create
conduits for delivery of oil or blood, monitor and maintain
those conduits, and intervene when they fail. Both
consistently seek less expensive, less traumatic methods
for achieving their goals. The research tools used to optimize
our industries are similar as well: metallurgy, finite
element analysis, computational fluid dynamics, stress
testing, and search for new durable materials. Blood and
oil are both non-Newtonian fluids that have remarkably
similar flow characteristics. Computational fluid dynamics,
a technique for analyzing how fluids flow, has been
largely developed in the oil and gas business and used
to optimize pipeline development. It is now emerging
as a central tool in understanding the dynamics of how
fluid flows in blood vessels in order to optimize device
development. Indeed, one of the early Pumps and Pipes
participants has evolved their CFD software for cardio-
vascular diagnosis. Likewise, finite element analysis
extensively employed for engineering of critical pump
components is now used to predict how and when aneurysms
rupture.
Houston is uniquely positioned to benefit from collaboration
between petroleum engineers and cardiovascular
researchers, mainly because Houston’s two leading
industries are oil and gas, and medicine. Both industries
are national and international leaders. The Texas Medical
Center, a consortium of medical schools, hospitals, and
universities, is the single largest medical complex in the
world. Houston also remains the unequivocal energy
capital of the world, housing both Exxon Mobil and
Shell’s largest research facilities. Although leadership
crossover occurs at the board level in many medical and
energy enterprises, this has not translated into a meaningful
technology exchange. Houston unfortunately has
virtually no medical device industry. Therefore, there is a
unique opportunity for our community to integrate and
leverage the synergy of these industries and technologies.
There is precedent for integrating medical and petroleum
know-how with resulting business success and a
MDCvJ | vII (1) 2011 45

Figure 1. Lazar
Greenfield, vascular
surgeon
positive impact on patient welfare. One such example
is the Kimray-Greenfield inferior vena cava filter that
is used clinically to prevent clots passing from the
legs to the lungs. Dr. Lazar Greenfield (Figure 1) was
prompted by a case of pulmonary embolus in a young
trauma patient. After opening the chest and performing
a pulmonary embolectomy, the patient died. Dr.
Greenfield sought better techniques to prevent pulmonary
embolus and asked Garman Kimmell (Figure 2),
an entrepreneur-inventor from the oil and gas industry,
for his help. Kimmell recognized the similar problem of
sludge in oil pipelines and how a conical filter trapped
the sludge at its center while still allowing flow around
it on the sides. Together they designed a prototype and
tested it in animals before implanting it in patients in the
early 1970s. The modern descendant is the stainless steel
Greenfield filter that has been implanted in more than
200,000 patients to date (Figure 3).
“Great invention is always metaphor,” says John Abele,
a co-founder of Boston Scientific Corporation, which
has manufactured the
Greenfield filter since
it acquired Kimmell’s
medical-device company
in 1980. “you look at the
problem, and then you
try to connect it to other
areas which may have
nothing to do with the
problem you’re working
on.”
Figure 3. Greenfield vena cava
filter.
Figure 2. Garman Kimmel,
oil-industry engineer, suggested
an implantable filter for trapping
blood clots before they can reach
the lungs.
Figure 4. Spiral Flow Vascular Access Graft (Tayside Flow
Technologies).
A. The novel graft design imparts a spiral laminar flow to the blood
delivering less turbulent flow energy to the venous anastomosis site.
B. Spiral Flow Inducer consists of an injection molded polyurethane
component that forms one 360° helical turn (HT) running along the
outside distal end of the graft.
C. Pre-cut venous anastomosis cuff.
D. Cross-section view of Spiral Flow Inducer showing injection molded
component (*).
E. Inside view of Spiral Flow Inducer showing ePTFE ridge (R) on the
graft lumen that imparts a rotational force on the blood exiting the graft
resulting in spiral laminar flow at the venous anastomosis site.
A Synergy of Industries
Tayside Flow Technologies, a small Scottish startup
company and participant in the Pumps and Pipes 3
Conference, has developed an artificial blood vessel that
mimics naturally occurring spiral flow patterns (Figure
4), thereby improving patency of bypass grafts. The same
technology is being studied to move oil through pipelines
with less frictional energy loss, thereby improving
efficiency. Indeed, pipeline engineers have long understood
the benefits of spiral flow patterns. There are other
crossovers as well. Remote monitoring, remote visualization,
3-D reconstruction of imaging data, automated
data analyses, use of simulators, robotics, and quality
improvement processes are all techniques common to
both industries, where opportunities exist for accelerated
learning.
The public was recently amazed at the clarity of visualization
and the dexterity of remote-controlled robots
in severing and capping the leaking blowout preventer
46 vII (1) 2011 | MDCvJ

one mile below the ocean surface following the Deepwater
Horizon disaster. visualization, remote control, and
tactile feedback are all key concepts in medical robotics.
Partly as a result of Pumps and Pipes interactions, we
have established the Cardiovascular Robotics Consortium
at the Methodist DeBakey Heart & vascular Center
where the principles of robot-assisted surgery can be
studied and developed to treat cardiovascular diseases.
The goals then of Pumps and Pipes 1, 2, 3 and 4 were
to expose medical researchers and oil and gas engineers
to similar technologies existing in the cardiovascular
medicine and energy industries and to explore opportunities
for developing “leap frog” technologies between
these like industries. To do this, we provided an interdisciplinary
platform to explore a series of topics of similar
innovations and challenges. Each topic had a discussant
from both the field of cardiovascular medicine and
from numerous companies within the energy sector
followed by an open discussion. Conference participants
have included engineers from medical and imaging
manufacturers, researchers and cardiovascular disease
specialists from within the Texas Medical Center, and
invited faculty with expertise in computational sciences
and bioengineering from the university of Houston,
Rice university, and Texas A&M university. The topics
Section 1. Docs and Rocks
Introduction and basic concepts. Let’s all talk the same language
The Doc: anatomy and physiology of the cardiovascular system — Dr. Lumsden (MDHVC)
The Rock: geology and physics of hydrocarbon production — Dr. Kline, Ph.D. (Exxon Mobil)
Section 2. Hydraulics, Conduits, and Pumps
Left ventricular assist devices — Dr. George Noon (MDHC)
Subsurface pumps — Rodney Bane (Exxon Mobil)
Staples, glues, and stitches — William E. Cohn (Texas Heart Institute)
Joints, welds, and cements — Rustom Mody (Baker Hughes Inc)
Atherosclerosis — chemical modification — Dr. Ballantyne (MDHVC)
Corrosion and scale management — Gerald Brown PE (Brown Corrosion Services Inc.)
Mechanical repair of blood vessels — Dr. Neil Kleiman (MDHVC)
Through tubing workovers — Li GAO, Ph.D. (Halliburton Energy Services)
Endovascular stents and stent grafts — Dr. Michael Silva
Expandable casing and liners — Mark Holland (Enventure Global Technologies)
Section 3. Accessing a Target
Navigating and viewing — Dr. Lumsden (MDHVC)
Geo-steering a drill bit — (Schlumberger)
Atherectomy and plaque analysis — Eric Peden (MDHVC)
Down hole coring and sampling — Fred Palumbo Jr. (Core Laboratories)
Section 4. Imaging and Monitoring
Medical imaging — Kin Li TMH, TMHRI
Oil & Gas imaging — Bruce Verwerst (Veritas DGC Inc)
Medical Image Computing — Ioannis A. Kakadriadis. Ph.D.(University of Houston)
Patient monitoring online — Faisal Masud (MDHVC)
Rapid flow stream analysis — Alan Schilowitz, Ph.D. (Exxon Mobil)
Meeting Highlights
Table 1. Topics in Pump and Pipes 1
covered in the Pumps and Pipes Symposia are listed
in Tables 1-3. The Pumps and Pipes conference, previously
held at the university of Houston, was moved
to the auditorium of the new The Methodist Hospital
Research Institute building for conference 4. The conference
will become international in scope and will be held
next in Qatar in April 2011.
Summary
The oil and gas industry is the world’s largest, with a
demand for capital in excess of $150 billion each year. By
collaborating with inventors, engineers, and other scientists
in the oil and gas industry, medicine stands to gain
from potential crossover ideas. One of the most tangible
and useful outcomes of the Pumps and Pipes initiative
was the widening of the researcher’s collaborative
network for problem solving. Like the development of
the Greenfield filter, some of our medical conundrums
already have solutions discovered by others. However,
many of the problems medical researchers face will
not have ready-made transference from the oil and gas
industry. The wealth of talent in different industries can
trigger profitable associations and creative solutions.
Pumps and Pipes provides the forum for this collaborative
brainstorming.
MDCvJ | vII (1) 2011 47

Welcome
Renu Khator, Ph.D. —Chancellor & President (University of Houston)
My Medical Toolkit — Alan B. Lumsden, M.D. (MDHVC)
My Oilfield Toolkit — William E. Kline, Ph.D. (ExxonMobil)
My Engineering Toolkit — Ioannis A. Kakadiaris, Ph.D. (University of Houston)
Oilfield Robotics — Ruston Mody (Baker Hughes)
Pipeline Robotic Connection — Kim Breaux (Quality Connector Systems)
Medical Robotics — Nikolaos Tsekos, Ph.D. (University of Houston)
Robot-Assisted High Throughout Experimentation — Rakesh Jain (Symyx Technologies)
Use of Magnetics for Device Positioning — William Cohn, M.D. (Texas Heart Institute)
Full Field Strain Mapping — John Tyson (Trillion Optical Systems)
Practical Development of Medical Robotics — Fred Moll, M.D. (Hansen Medical)
Inside Wall Imaging — Steven Hansen (Schlumberger Global Geology)
Intravascular Imaging Catheters — Mark Davies, M.D., Ph.D. (The Methodist Hospital)
Mapping Surfaces at the Molecular Level — Dalia Yablon, Ph.D. (ExxonMobil)
(Structural) Health Monitoring Using (Vibration) Signature Changes — Kurt Steffen (ExxonMobil)
Belief Networks in Geosciences — Osama Gabber, M.D. (The Methodist Hospital)
Membranes and Filters — C. Vipulanandan (University of Houston)
Nonmaterial’s: Present and Future — Alan Lumsden, M.D. (MDHVC); William E. Kline, Ph.D. (ExxonMobil); Ioannis A. Kakadiaris,
Ph.D. (University of Houston)
Vision: Pumps and Pipes III and Beyond
Table 2. Topics in Pump and Pipes 2
Session I. Pumps & Circuits—Tales From The Toolbox
Indestructible Pumps—Here’s the Idea…
Ideas Everywhere: My P&P Clippings File — William Kline, Ph.D. (ExxonMobi)
A New Idea for Supporting the Heart — Basel Ramlawi, M.D. (MDHVC)
Nanotechnology & Robotics — Fantastic Voyage
Anything You Can Do, I Can Do Smaller — Li Sun, Ph.D. (University of Houstoni)
I, Robot — Going New Places, Doing New Things — Jean Bismuth, M.D. (MDHVC)
Distant Monitoring & Surveillance — Reach Out & Touch Someone
You Think Your Long Distance Bill is High? — William Standifird (Halliburton)
Sensors: Please Call Homes — Rebecca Seidel & Steven Glinski (Medtronic)
Panel Roundtable: Pumps & Circuits — Billy Cohn, M.D. — Moderator (Texas Heart Institute)
Interactive Break-out Workshops
Lunch and Guest Speaker — Joe Cunningham, M.D. (Sante’ Ventures)
Session II. Pumps And Pipes — Across the Backyard Fence
Managing Imperfect Conduits — 40 Miles of Bad Roads
Stent Technology: Keeping the Road Open — Michael Nilson (Gore Medical Products)
Porous Media Flow: When Google Map is Not Enough — Karsten Thompson, Ph. D. (Louisiana State University)
Intelligent Conduits — Where All Conduits are Above Average
Field of the Future — Bill Blosser (British Petroleum)
From Blood Vessels to Pipelines — Peter Stonebridge, M.D. (Dundee University and Flow Technology, Ltd.)
Advanced Materials — The Devil Wears Prada
Designer Materials I — Rustom Mody, Ph.D. (Baker Hughes)
Designer Materials II — Ramanan Krishnamoorti, Ph.D. (University of Houston)
Panel Roundtable: Pipes & Fluids — Heitham Hassoun, M.D., Moderator (MDHVC)
Interactive Breakout Workshops
Bringing People and Ideas Together: NSFI/UCRC on Pumps and Pipes — Ioannis Kakadiaris, Ph. D. (University of Houston)
Closing Remarks — Renu Khator, Ph.D. (University of Houston Chancellor & President)
Pumps & Pipes 3 Wrap–Up — William Kline, Ph.D.(ExxonMobil) & Alan Lumsden, M.D. (MDHVC)
Table 3. Topics in Pump and Pipes 3
48 vII (1) 2011 | MDCvJ

N. Kleiman, M.D. M.J. Reardon
Introduction
TAvI: TRANSCATHETER AORTIC
vALvE IMPLANTATION
Neal Kleiman, M.D.; Michael J. Reardon, M.D.
Methodist DeBakey Heart & Vascular Center, Houston, Texas
Aortic valvular stenosis is a disease with a
long latent period followed by rapid progression
to death after the onset of symptoms.
The classic series by Ross and Braunwald
reports an average survival of 2 to 5 years
after symptom onset (Figure 1). 1 There is no
medical therapy proven to extend survival.
Fortunately, surgical aortic valve replacement
(AVR) is now done with an operative
mortality of 3% to 4% for isolated AVR and
5.5% to 6.8% for AVR combined with coronary artery bypass (CAB) 2 and with a 10-year survival that
averages a little over 60%. The success we have seen with surgical AVR is complicated by an increase in
aortic stenosis with age combined with the aging of our population itself. It is estimated that by 85 years
of age, 8% of the population will have aortic stenosis. 3 Surgical series have been reported with operative
mortality of 2% for AVR in patients 80 years and older, 4 Figure 1. Survival in adults with aortic stenosis
but increasing age is associated with increasing
risk, and not all patients that meet guideline criteria for AVR are offered therapy.
It was recently reported in a survey of European centers that 31.8% of patients with severe, isolated,
symptomatic aortic stenosis were not offered surgical therapy due to risk level, comorbidities, or patient
refusal. 5 A large academic medical center in the United States reported a review of echocardiographic
results from their institution that showed only 453 out of 740 patients (61%) with severe aortic stenosis
— defined as aortic valve area (AVA) of 0.8 cm 2 or less — received surgery. 6 In the United States, it is
estimated that about 749,000 patients have aortic stenosis and, of these, 125,000 have severe stenosis.
This can be compared to the estimated number of AVR operations done in the United States annually of
70,000. It is clear that there is a substantial population with severe, life-threatening aortic stenosis that is
underserved. This has led to the search for less morbid treatment options for aortic stenosis.
MDCvJ | vII (1) 2011 49

Treatment of Aortic Stenosis
Aortic stenosis is a mechanical obstruction to left
ventricular outflow. As the impedance to outflow
persists, left ventricular hypertrophy results from
increased cardiac work and eventually leads to cardiac
failure and decompensation. Effective treatment must
incorporate relief of the mechanical obstruction. Surgical
AvR provides complete excision of the stenotic native
valve and replacement with a minimally obstructing
prosthetic valve.
Temporary relief of obstruction may be obtained by
percutaneous balloon aortic valvuloplasty (BAv). The
technique was first used in the 1980s, but its use was
diminished when the high rate of recurrent valvular
stenosis (>50%) became evident. Modest reduction of
gradient and increase in AvA are seen following BAv,
and the procedure is very effective in relieving the
symptoms of congestive heart failure (CHF). However,
the increments in AvA are small (valve rarely exceeds
1.0 cm 2 ), recurrent symptoms usually occur within 6
months, and the long-term survival is not different
from untreated aortic stenosis. 7 In the last several years,
BAv has seen increased use as a bridge to surgery for
patients with severe heart failure and as a temporizing
therapy in patients with severe symptomatic disease
who are not candidates for operative valve replacement.
The increase in its use is due at least in part to improvements
in balloon technology, allowing lower profiles that
are less likely to damage the iliofemoral vessels, and to
the adaptation of rapid ventricular pacing to eliminate
cardiac ejection during balloon inflation, thus allowing
the balloon’s position to remain stable during inflation.
As a result of the imperfect physiological and unsatisfactory
clinical outcomes of BAv, the concept developed that
a stent-mounted valve could be used to maintain its early
success.
In a proof-of-concept experiment, Andersen reported
in 1992 the placement of a stent-mounted valve inside
of the native valve of pigs. 8 In 2002, Cribier reported
the first-in-man transcatheter aortic valve implantation
(TAvI). 9 Since this first success, there has been an explosion
of interest in and technology for TAvI. Currently
there are 2 catheter-based aortic valve systems available
in Canada and Europe, where more than 12,000
implants have been performed. These are the SAPIEN
valve (Edwards Lifesciences, Inc.) and the Corevalve
(Medtronic, Inc.). The SAPIEN valve is balloon-expandable
while the Corevalve is self-expanding. Both valve
delivery systems are large (18–24 Fr), and insertion of
either prosthesis requires a fair amount of operator skill.
The Edwards SAPIEN valve has been studied in the
Figure 2. SAPIEN Valve (Edwards, Inc.)
Placement of Aortic Transcatheter valves (PARTNER)
trial in the united States. The trial was a multicenter
randomized clinical trial comparing TAvI with standard
medical therapy (including BAv) in patients with severe
aortic stenosis and high-risk surgical features. The first
arm of the study compared TAvI to best medical therapy
(including BAv) in patients thought not to be surgical
candidates due to extreme risk. Mortality at the end
of one year was 30.7% for TAvI and 50.7% for standard
medical therapy, and heart failure symptoms of NyHA
classes III or Iv were 25.3% versus 58%. 10 The results of
the second arm of the study, in which TAvI is compared
to surgical AvR, are pending. A second trial with the
Medtronic Corevalve is underway. Trial design is very
similar to the PARTNER trial with two trial arms. The
first arm will compare TAvI with the Corevalve versus
best medical therapy with patients randomized 2:1. The
second arm will be TAvI versus open surgical AvR
randomized 1:1.
Several important design differences distinguish the
Corevalve from the SAPIEN system. The SAPIEN valve
consists of a trileaflet bovine pericardial valve that is
mounted within a stainless steel stent (Figure 2). Prior
to implantation, the valve is crimped by the operator
onto a delivery balloon. The native valve is prepared for
implantation by BAv. The prosthetic valve is then delivered
through the femoral artery to the aortic annulus.
Once satisfactory positioning is achieved, rapid atrial
pacing is performed and the implantation balloon is
inflated. In patients with severe iliac disease with vessels
that are too small to allow transfemoral delivery of the
valve, implantation can be performed via a small thoracotomy
allowing transapical implantation through the
left ventricle. Following implantation, the ventriculotomy
is repaired by surgical closure with a purse-string suture.
50 vII (1) 2011 | MDCvJ

Figure 3. CoreValve (Medtronic, Inc.) Figure 4. Balloon aortic valvuloplasty initial
picture
Structure of Corevalve System
The Corevalve Revalving System consists of three
separate components: the valve itself, which is a selfexpanding
Nitinol support frame with a trileaflet porcine
pericardial tissue valve and anchoring skirt sutured
to the frame; a catheter delivery system; and a disposable
valve loading system. The valve forms the central
component and is anchored to a self-expanding radiopaque
Nitinol frame that holds the tissue valve in
position. The Nitinol frame has three distinct levels of
diameter with varying hoop and radial strength (Figure
3). The inflow portion of the frame exerts high radial
force against the left ventricular outflow tract to allow
secure fixation. This area exerts a constant centrifugal
force that allows the valve to adjust to varying annular
sizes during implantation and will help mitigate paravalvular
leak over time. The skirt portion of the pericardial
Figure 6. CoreValve initial deployment
Figure 7. CoreValve two-thirds deployment
Figure 5. Balloon aortic valvuloplasty after
inflation
valve is sutured to this portion of the frame to achieve a
seal to the annulus. The center section that contains the
actual valve leaflets is constrained to allow coronary flow.
It exhibits a high hoop strength to resist any deformation
from the native valve leaflets. In this configuration, the
valve actually sits in a supra-annular plane. The outflow
portion has the largest diameter and a low radial force.
This portion of the valve is not engaged in the anchoring
process and serves to orient the valve to the aorta. This
portion of the frame also contains the loading loops used
to secure the valve to the delivery system (Figure 3).
There are two separate sizes available that will cover the
majority of annular sizes. The proper size is chosen based
on imaging studies of the aortic root. Access is gained via
the femoral artery either by cut down or percutaneously.
The proper sized valve is then prepared and hand-loaded
onto the 18-Fr catheter delivery system using the dispos-
MDCvJ | vII (1) 2011 51

able loading tool from the Corevalve ReSizing System. The
patient’s native aortic valve is prepared for Corevalve
insertion with BAv under rapid pacing (Figures 4 and 5).
After BAv, the valve is positioned across the native aortic
valve, which allows several mm of the inflow portion to
sit below the annulus to allow anchoring (Figure 6). Once
the inflow portion is seated properly, the valve is rapidly
deployed to about two-thirds release. This allows flow
to resume through the new Corevalve while maintaining
attachment to the delivery system to allow outward
adjustment if necessary (Figure 7). An aortogram is
performed at this point to confirm positioning and, if
correct, the rest of the valve is deployed and the delivery
system removed. A final arteriogram is done to confirm
final position, and an echocardiogram is done to check
valve function, gradient, and paravalvular leak.
The Methodist DeBakey Heart & vascular Center is
excited to participate in this trial. Additional information
about the trial or participation in the trial is available at
our multidisciplinary valve clinic site, available at www.
debakeyheartcenter.com/valveclinic.
References
1. Ross J Jr, Braunwald E. Aortic stenosis. Circulation.
1968;38(1 Suppl):61-7.
2. American College of Cardiology/American Heart Association
Task Force on Practice Guidelines; Society of
Cardiovascular Anesthesiologists; Society for Cardiovascular
Angiography and Interventions; Society of Thoracic
Surgeons, Bonow RO, Carabello BA, Kanu C, de Leon AC
Jr, Faxon DP, Freed MD, Gaasch WH, Lytle BW, Nishimura
RA, O’Gara PT, O’Rourke RA, Otto CM, Shah PM, Shanewise
JS, Smith SC Jr, Jacobs AK, Adams CD, Anderson JL,
Antman EM, Faxon DP, Fuster v, Halperin JL, Hiratzka LF,
Hunt SA, Lytle BW, Nishimura R, Page RL, Riegel B. ACC/
AHA 2006 guidelines for the management of patients with
valvular heart disease: a report of the American College
of Cardiology/American Heart Association Task Force on
Practice Guidelines (writing committee to revise the 1998
Guidelines for the Management of Patients With valvu-
lar Heart Disease): developed in collaboration with the
Society of Cardiovascular Anesthesiologists: endorsed by
the Society for Cardiovascular Angiography and Interventions
and the Society of Thoracic Surgeons. Circulation.
2006 Aug 1;114(5):e84-231.
3. Ambler G, Omar RZ, Royston P, Kinsman R, Keogh BE,
Taylor KM. Generic, simple risk stratification model for
heart valve surgery. Circulation. 2005 Jul 12;112(2):224-31.
Epub 2005 Jul 5.
4. Davidson MJ, Cohn LH. Surgeons’ perspective on percutaneous
valve repair. Coron Artery Dis. 2009 May;20(3):192-8.
5. Iung B, Baron G, Butchart EG, Delahaye F, Gohlke-Bärwolf
C, Levang OW, Tornos P, vanoverschelde JL, vermeer F,
Boersma E, Ravaud P, vahanian A. A prospective survey
of patients with valvular heart disease in Europe: The
Euro Heart Survey on valvular Heart Disease. Eur Heart J.
2003 Jul;24(13):1231-43.
6. varadarajan P, Kapoor N, Bansal RC, Pai RG. Clinical
profile and natural history of 453 nonsurgically managed
patients with severe aortic stenosis. Ann Thorac Surg. 2006
Dec;82(6): 2111-5.
7. Wang A, Harrison JK, Bashore TM. Balloon aortic valvuloplasty.
Prog Cardiovasc Dis. 1997 Jul-Aug;40(1):27-36.
8. Andersen HR, Knudsen LL, Hasenkam JM. Transluminal
implantation of artificial heart valves. Description
of a new expandable aortic valve and initial results with
implantation by catheter technique in closed chest pigs.
Eur Heart J. 1992 May;13(5):704-8.
9. Cribier A, Eltchaninoff H, Bash A, Borenstein N, Tron C,
Bauer F, Derumeaux G, Anselme F, Laborde F, Leon MB.
Percutaneous transcatheter implantation of an aortic valve
prosthesis for calcific aortic stenosis: first human case
description. Circulation. 2002 Dec 10;106(24): 3006-8.
10. Leon MB, Smith CR, Mack M, Miller DC, Moses JW,
Svensson LG, Tuzcu EM, Webb JG, Fontana GP, Makkar
RR, Brown DL, Block PC, Guyton RA, Pichard AD, Bavaria
JE, Herrmann HC, Douglas PS, Petersen JL, Akin JJ,
Anderson WN, Wang D, Pocock S; PARTNER Trial Investigators.
Transcatheter aortic-valve implantation for aortic
stenosis in patients who cannot undergo surgery. N Engl J
Med. 2010 Oct 21;363(17):1597-607. Epub 2010 Sep 22.
52 vII (1) 2011 | MDCvJ

H.J. Safi, M.D.
IN TRIBuTE:
ERNEST STANLEy CRAWFORD, M.D.
Hazim J. Safi, M.D.
E. Stanley Crawford, M.D., was a pioneer and a giant
in cardiovascular surgery. His particular specialty
was aortic sugery. Born on May 12, 1922, in Evergreen,
Alabama, Dr. Crawford graduated Phi Beta Kappa from
the university of Alabama and subsequently attended
Harvard Medical School, where he graduated Alpha
Omega Alpha. He then served as a lieutenant in the
united States Navy from 1947–1949 at the u.S. Naval
Hospital in Portsmouth, New Hampshire. After leaving
the Navy, he met and married his lovely wife, Carolyn,
and completed his postgraduate surgical training at
Massachusetts General Hospital. He then began working
with Dr. Michael E. DeBakey in Houston, where
he stayed and eventually became a professor at Baylor
College of Medicine.
Dr. Crawford’s contributions to aortic surgery were
monumental. Among them were thoracoabdominal
aortic aneurysm repair, inclusion technique, reattach-
in MeMoriuM
May 12, 1922 – October 27, 1992
ment of small arteries to the large artery, reattachment
of intercostal arteries into the graph, repair of ascending
aneurysm, repair of arch aneurysm, repair of aortic
dissection, treatment of Marfan’s syndrome, treatment
of carotid artery disease, treatment of peripheral vascular
disease, and being the first to successfully replace
the entire aorta with a Dacron graft. He moved the
management of difficult and vexing aortic problems to
the realm of everyday treatment. Through diligent work
and attention to details, he revolutionized the treatment
of problems that had been plagued with a higher rate of
paralysis from the waist down, stroke, and death.
My first encounter with Dr. Crawford was in April
1979, when I was a fourth-year surgical resident. It was
a rough start, but he was interested in other people’s
backgrounds, and the more we talked about our respective
upbringings, the more we liked each other. I was
in awe of his technical skill. His eye-hand coordination
MDCvJ | vII (1) 2011 53

was — and is still — unmatched with any surgeon I’ve
ever seen. It was following my rotation at King Faisal
Hospital in Saudi Arabia, where Baylor was running
their cardiovascular program, that I received a phone
call on June 20, 1983. I was in a Safeway, shopping with
my son and wife. His now familiar southern voice
boomed over the line: “Dr. Safi, do you want to join me
this summer as an associate?”
I replied, “Well, it’s better than being unemployed!”
He laughed, and I joined him in July 1983. The following
year, my colleague Joseph S. Coselli joined us, and
we worked together for the rest of Dr. Crawford’s clinical
career.
Thus began a period of great innovation in the repair
of aneurysms. Dr. Crawford shaped my surgical and
academic thinking, and I am where I am now because
of his impact on me then. It was a period marked by
extensive writing and one that shaped what the vascular/aortic
community in this country (as well as the
world) thought with regard to aneurysm repair. Dr.
Crawford became an international figure and was miles
ahead of everybody. Despite this, he shunned publicity
and was averse to giving interviews to the media. Part
of this was his shy personality, and part was his constant
remembrance of the humble roots from which he
came.
In fact, his roots spurred in him a desire to help
others that was uncommon in its sincerity. He used to
take residents under his wing who had been dismissed
for one reason or another. More than that, his support
of his associates was steadfast and without question.
His treatment of everyone as equals was unparalleled.
When John Crawford and Mathew uribe joined our
practice in 1983, he demanded the same high standard
of them that he would of anyone else. It was also during
this time that I became friends with his late wife and
his family — John, Bruce, and Clay.
Dr. Crawford was my mentor and friend. One of my
fondest memories was when we would operate into
the wee hours of the night. We used to sit in the coffee
room attached to the Fondren-Brown operating room
and discuss family, friends, politics and culture. One
of these nights he told me that when he was young, he
used his father’s razor to make a circular cut around a
mattress. I retorted, “And you never stopped.” yet what
impressed me more during these hours of discussion
was that he was open minded and accepting of new
ideas as long as they were tested scientifically. That was
the root of Dr. Crawford’s success; it always led him
to ask the questions that propelled progress. I can still
hear him telling me with his familiar southern twang,
“I’m ready for good results.”
As I look back to the last 18 years since his departure
from this life, his legacy still lives on. The current
challenges we face in aortic surgery, whether using
endovascular or open technique, are all built on the successful
foundations that Dr. Crawford laid during his
career. Apart from Dr. DeBakey, no one else besides
Dr. Crawford has had a bigger impact on my career. I
tried on many occasions to thank him, but he would
always shun the compliment and say, “All I did was
crack the door open; the rest is you.” I remember when
it was said that the replacement of the entire aorta from
the valve to the iliac bifurcation was impossible. That
was before Dr. Crawford proved them wrong. He was
the key that opened the door to make aortic surgery a
common practice for all of us. Truly, he was the giant on
whose shoulders we still stand looking out afar as we
continue to fulfill his legacy.
Acknowledgement to Joseph Safi for editorial assistance.
54 vII (1) 2011 | MDCvJ

MuseuM of tMH MultiModality iMaging Center
Diastolic Mitral Valve Regurgitation. A 41-year-old man was referred to Methodist with suspected bacterial endocarditis. 2-D
echocardiography was performed and a large aortic valve vegetation was identified along with severe aortic regurgitation. Panel A depicts
a mildly enlarged left ventricle (5.9 cm diameter) with open mitral leaflets near end-diastole. Color Doppler demonstrates simultaneous aortic
regurgitation (AR) and mitral regurgitation (MR). Panel B depicts a continuous wave Doppler signal across the mitral valve. Regurgitant mitral
flow begins 80ms before the onset of systole. In general, diastolic MR is diagnostic of highly elevated left ventricular end-diastolic pressure.
For this patient, the presence of diastolic MR confirmed that the aortic regurgitation was severe and likely acute. In this era of increasingly
sophisticated imaging technologies, it is important to continue to recognize these classic Doppler findings.
Image courtesy of Stephen H. Little, M.D.
Cardiac Computed Tomography
Angiogram. Cardiac computed
tomography angiogram (CTA) of a 48-yearold
male with atypical chest pain. A small
muscular ventricular septal defect (arrow)
with left to right shunting as shown by the
passage of iodinated contrast from left
ventricle (LV) to right ventricle (RV).
Image courtesy of Su Min Chang, M.D.
MDCvJ | vII (1) 2011 55

The Methodist Hospital
chosen for percutaneous
valve replacement study
Study evaluates replacing
heart valve through tiny
puncture hole
MetHodist de Bakey Heart & VasCular Center update
HOuSTON (Jan. 24, 2011) —
The Methodist DeBakey Heart &
vascular Center was chosen today
as a site for a critical percutaneous
heart valve study. As part of the
research study, Methodist physicians
will replace diseased cardiac
valves through a single, tiny puncture
hole in the research subject’s
groin.
“using this new technique in the
study, we will be able to replace
severely calcified and damaged
aortic valves without open heart
surgery or removal of the original
diseased valve,” said Dr. Neal
Kleiman, director of the catheterization
labs at the Methodist
DeBakey Heart & vascular Center
and cardiology principal investigator
for the trial. “This study is the
only way individuals have access
to this technique in the united
States.”
The Medtronic Corevalve ®
System, which is delivered into
the individual’s heart via catheter,
has been implanted in more than
12,000 patients worldwide and is
available in 34 countries outside
the united States.
The trial incorporates expertise
of both cardiac surgeons and cardiologists.
using this technique,
physicians make a tiny puncture
hole in the individual’s groin and
In the news
thread a catheter through the
femoral artery into the heart. The
valve is delivered to the site of the
diseased aortic valve through the
catheter, and then the new valve
is deployed inside the individual’s
original valve, thus providing the
individual with a functioning valve
to allow for effective blood flow.
“We routinely perform surgical
valve replacement for diseased
aortic valves, but many individuals
are too high a risk for open-heart
surgery due to age or other illness,
said Dr. Michael Reardon, cardiac
surgeon at Methodist and surgical
principal investigator for the
trial. “In this trial, we will evaluate
whether catheter based aortic valve
replacement will help extend the
lives of this group of individuals.”
Worldwide, approximately
300,000 people have been diagnosed
with this condition (100,000
in the united States), and approximately
one-third of these patients
are deemed at too high a risk for
open-heart surgery,[i] the only therapy
with significant clinical effect
that is currently available in the
united States.
Traditionally, a valve is replaced
with a tissue or mechanical valve
during open-heart surgery, which
requires a surgical incision and
a one month recovery period.
Transcatheter valve replacement
is being studied in part to evaluate
recovery times and exposure to
side affects of major surgery.
In July, Methodist opened a new
hybrid, robotic operating suite that
integrates advanced robotics, imag-
ing and navigation with surgery to
offer patients the least invasive and
safest surgical and interventional
treatments for cardiovascular disease.
“The new suite is perfectly
designed for advanced procedures
like the percutaneous valve,” said
Dr. Alan Lumsden, medical director
of the Methodist DeBakey
Heart & vascular Center in
Houston. “The clear 3-D imaging
we have in this new room enables
us to maneuver the valve into
place and position it much more
accurately and precisely than ever
before. This is vitally important in
such an advanced technique.”
Methodist will be one of 40 sites
in the country studying this new
technique. The study investigators
are currently screening subjects for
enrollment. Methodist will enroll
approximately 100 patients over the
course of the trial. The Medtronic
Corevalve u.S. Pivotal Clinical
Trial will enroll a total of more
than 1,300 patients in the united
States. Outside the united States,
Corevalve received CE (Conformité
Européenne) Mark in Europe in
2007.
For more information on the
Methodist DeBakey Heart &
vascular Center, visit www.
debakeyheartcenter.com.
[i] Iung B, Cachier A, Baron G, et al.
Decision-making in elderly patients
with severe aortic stenosis: why are
so many denied surgery? Eur Heart J.
2003;26:2714-2720.
56 vII (1) 2011 | MDCvJ

Introduction
CT Coronary Angiography: When Should It
Be Performed?
Selim R. Krim, M.D. a ; Rey P. Vivo, M.D. a ;
Su Min Chang, M.D. b
a University of Texas Medical Branch, Galveston, Texas; and
b Methodist DeBakey Heart & Vascular Center, Houston, Texas
Over the past decade, technological advances in
multidetector computed tomography (CT) with submillimeter
spatial resolution and almost heart-freezing
temporal resolution have enabled the accurate noninvasive
assessment of coronary arteries. Multiple studies
have shown that CT coronary angiography (CTCA) has
a high sensitivity, good specificity and, in particular,
an extremely high negative predictive value, making
it an attractive imaging modality to rule out the presence
of coronary artery disease (CAD). Furthermore,
CTCA depicts the presence of nonobstructive coronary
plaques and has been used for prognosticating future
coronary events. CTCA is now considered by many as a
noninvasive imaging modality of choice that supplants
invasive angiography for assessing obstructive CAD
in selected patient populations. It is also now recognized
as an “appropriate” procedure in several selected
clinical scenarios, including: 1) evaluation of chest pain
syndrome with uninterpretable or equivocal stress test;
2) evaluation of chest pain syndrome in patients with
intermediate pre-test probability of CAD; and 3) acute
chest pain with intermediate pre-test probability of
CAD, no ECG changes, and negative serial enzymes.
Other applications of CTCA include the diagnosis of
coronary anomalies. Despite its many advantages and
promising clinical results, many concerns related to
inappropriate use have been raised due to radiation
exposure and use of iodinated contrast material. It is
considered inappropriate to use CTCA as a screening
tool in asymptomatic patients. In addition, it is recom-
aBstraCts
The following abstracts were selected from those presented at the conference on Multimodality
Cardiovascular Imaging for the Clinician: Update in Echocardiography, Nuclear, CT and CMR held in
Houston, Texas, October 2–3, 2010 under the direction of Dr. William Zoghbi and co-chaired by
Drs. Miguel Quiñones, John Mahmarian, and Dipan Shah.
This conference was designed to address the conundrum of clinicians in choosing the best imaging
procedure from the many now available choices for a particular clinical problem thus avoiding the time and
expense of multiple imaging procedures.
mended that CTCA use be avoided in patients who
have chronic kidney disease, a severe reaction to contrast
material, and a rapid or irregular heart rate.
Live 3-D Imaging Facilitates Percutaneous
Paravalvular Repair
Stephen H. Little, M.D. a ; Neal Kleiman, M.D. a ; Sasidhar
Guthikonda, M.D. b
aThe Methodist DeBakey Heart & Vascular Center, Houston,
Texas; and bPiedmont Heart Institute, Piedmont Hospital,
Atlanta, Georgia
Overview: Our initial experience using live threedimensional
transesophageal echocardiography (3-D
TEE) during percutaneous paravalvular repair (PPvR)
is described. We report that 3-D TEE enables real-time
catheter visualization and facilitates occluder device
placement across regurgitant mitral paravalvular
defects (PD).
Purpose: 3-D TEE (Philips, uSA) was employed
during four consecutive PPvR procedures. Image
guidance by 2-D TEE and 3-D TEE was qualitatively
compared for 1) assessment of the structural defect location
and geometry, 2) continuous catheter visualization,
and 3) evaluation of closure device position and function.
Methods: Five occluder devices (Amplatzer PDA,
uSA) were successfully positioned across large PDs in
three patients. Patient 1 — single occluder deployed
for mechanical mitral PD; patient 2 — 2 occluders
deployed for mechanical mitral PD, a third adjacent
occluder deployed 5 months later (Figure 1); patient 3
— single occluder deployed for bioprosthetic mitral PD.
Compared to 2-D TEE, supplemental imaging by 3-D
TEE was of immediate value. Live 3-D/color Doppler
imaging clearly identified the size, location, and crescent-like
geometry of significant mitral paravalvular
MDCvJ | vII (1) 2011 57

defects. useful display modes were: 1) Live 3-D Zoom
during transeptal puncture and to identify dynamic
catheter position relative to en-face views of the valve;
and 2) Live 2-D biplane display (of 3-D data) to identify
and track the guide wire tip during positioning across
the PD. After device deployment, 3-D/color Doppler
imaging provided immediate evaluation of occluder
position and procedure success.
Conclusion: Live 3-D TEE during PPvR provides
important additive value regarding structural defect
geometry, device delivery guidance, and immediate
assessment of procedural success.
Role of Cardiac Imaging in CRT
Sherif F. Nagueh, M.D.
Methodist DeBakey Heart & Vascular Center, Houston, Texas
Congestive heart failure (CHF) carries a high mortality
and is the leading cause of hospitalizations in
the united States. Despite optimal medical therapy,
many patients with CHF — due to a depressed EF —
remain symptomatic. In these patients who also have
a prolonged QRS duration, CRT has shown favorable
effects on Lv function along with a significant reduction
in adverse clinical events. However, around 30% of
patients who receive CRT do not show clinical or functional
improvement. Cardiac imaging can help identify
patients who are more likely to benefit from CRT. This
includes the assessment of the presence, severity and
extent of mechanical dyssynchrony. At the present time,
echocardiography is the most practical modality for this
purpose due to its high temporal resolution. Several
techniques have been evaluated including: M-mode,
3-D, tissue Doppler, and speckle tracking. In addition,
it is possible to identify the site with latest mechanical
activation, and the presence or absence of contractile
reserve. using echocardiography and cardiac magnetic
resonance, it is possible to study the presence and distribution
of scar tissue, which is one of the important
Figure 1. 3-D TEE imaging
assists in deploying and
visualizing occluders used for
repairing mitral paravalvular
defects.
factors that can predict the occurrence of reverse remodeling
after CRT.
The Role of Cardiovascular Magnetic
Resonance in Detecting Coronary Artery
Disease
Dipan J. Shah, M.D.
Methodist DeBakey Heart & Vascular Center, Houston, Texas
With recent technical and clinical advances, cardiovascular
magnetic resonance (CMR) has evolved from a
promising research tool to an everyday clinical tool that
is considered a competitive first-line test for common
indications, such as detection of coronary artery disease
(CAD). In fact, a 2006 consensus panel from the
American College of Cardiology Foundation deemed
the following indications as appropriate uses of stress
perfusion CMR: evaluating chest pain syndromes in
patients who have an intermediate probability of CAD
with uninterpretable resting ECG or the inability to
exercise; evaluating suspected coronary anomalies; and
ascertaining the physiologic significance of indeterminate
coronary artery lesions detected on coronary
angiography (catheterization or CT). Currently, there
are several CMR approaches for detecting coronary
artery disease, including coronary magnetic resonance
angiography (MRA), pharmacologic stress CMR with
dobutamine (to assess contractile reserve and inducible
wall motion abnormalities), and pharmacologic stress
CMR with adenosine (to assess myocardial perfusion).
Coronary MRA may be used to directly visualize
coronary anatomy and morphology, but it is technically
demanding. The coronary arteries are small
(3–5 mm) and tortuous compared with other vascular
beds that are imaged by MRA, and there is nearly
constant motion during the respiratory and cardiac
cycles. To counter these difficulties, several technical
advancements have been made in recent years, including
the advent of ultrafast steady-state free precession
58 vII (1) 2011 | MDCvJ

sequences that offer superior signal-to-noise ratio in
combination with whole-heart approaches analogous to
multidetector CT. These sequences typically can be run
with submillimeter in-plane spatial resolution (0.8–1.0
mm) and slice thickness slightly more than 1 mm, and
they generally require 10 minutes to perform. While
this spatial resolution is insufficient to routinely assess
for native vessel coronary stenosis, it is sufficient for
identifying anomalous coronary arteries or coronary
artery aneurysms.
Stress testing with imaging of myocardial contraction
can provide information concerning the presence and
functional significance of coronary lesions. Dobutamine
stress CMR to detect ischemia-induced wall motion
abnormalities is an established technique for diagnosing
coronary disease and is performed in a manner
analogous to dobutamine echocardiography. It has been
shown to yield higher diagnostic accuracy than dobutamine
echocardiography 1 and can be effective in patients
not suited for echocardiography because of poor acoustic
windows. Logistic issues regarding patient safety
and adequate monitoring are nontrivial matters that
require thorough planning and experienced personnel.
Stress perfusion CMR with adenosine has existed
for nearly two decades with numerous clinical validation
studies demonstrating average sensitivity and
specificity of 84% and 80% respectively for detection of
coronary stenosis in comparison to X-ray coronary angiography.
2 These studies used various imaging protocols,
and many used a quantitative approach for diagnostic
assessment. Although a quantitative approach has the
potential advantage of allowing absolute blood flow to
be measured or parametric maps of perfusion to be generated,
the approach is laborious and requires extensive
interactive post-processing; this makes it unfeasible for
everyday clinical use.
Recently we have published a multicomponent
approach to CMR stress testing that can generally be
performed in less than one hour and includes the following:
1) cine CMR for assessing cardiac morphology
and regional and global systolic function at baseline, 2)
stress perfusion CMR to visualize regions of myocardial
hypoperfusion during vasodilation (e.g., with adenosine
infusion), 3) rest perfusion CMR to aid in distinguishing
true perfusion defects from image artifacts, and 4)
DE-CMR for determining myocardial infarction. 3 We
demonstrated that the determination of CAD using the
multicomponent CMR stress test significantly improved
diagnostic performance, yielding a sensitivity rate of
89%, a specificity rate of 87%, and a diagnostic accurac
rate of 88%.
In conclusion, CMR is a useful imaging modality
for detection of CAD. Coronary MRA approaches have
demonstrated utility in assessment of coronary artery
anomalies or aneurysms. Pharmacologic stress CMR
(either of myocardial contraction or perfusion) is useful
for detecting CAD or for determining the physiologic
implication of stenosis of unclear significance detected
on coronary angiography. CMR approaches offer several
advantages over competing modalities in that they
can generally be performed in less than an hour and do
not require administration of ionizing radiation.
References
1. Nagel E, Lehmkuhl HB, Bocksch W, et al. Noninvasive
diagnosis of ischemia-induced wall motion abnormalities
with the use of high-dose dobutamine stress MRI:
comparison with dobutamine stress echocardiography.
Circulation. 1999 Feb 16;99(6):763–70.
2. Shah DJ, Kim HW, Kim RJ. Evaluation of ischemic heart
disease. Heart Fail Clin. 2009 Jul;5(3):315-32.
3. Klem I, Heitner JF, Shah DJ, Sketch MH Jr, Behar v, Weinsaft
J, Cawley P, Parker M, Elliott M, Judd RM, Kim RJ.
Improved detection of coronary artery disease by stress
perfusion cardiovascular magnetic resonance with the use
of delayed enhancement infarction imaging. J Am Coll
Cardiol. 2006 Apr 18;47(8):1630-8. Epub 2006 Mar 27.
Appropriate Use Criteria (AUC) for
Cardiovascular Imaging
Raymond F. Stainback, M.D.
Texas Heart Institute, Houston, Texas
Cardiovascular (Cv) imaging use has increased substantially
over the last 10 years. The reasons remain
complex and partially defined. In 2005, the American
College of Cardiology Foundation (ACCF) began a
systematic process for determining imaging “appropriateness
criteria,” now known as the “appropriate use
criteria” (AuC). For each major Cv imaging modality,
the modified Delphi Method was employed for determining
AuC. 1 AuC were constructed using a three-step
approach: 1) an expert writing group establishes a set
of imaging and patient-specific “assumptions” along
with a set of clinical scenarios (indications) for common
anticipated uses; 2) external reviewers (other experts
and stakeholders) critique the indications and suggest
revisions; and 3) a diverse technical panel rates the
clinical indications as appropriate (A), uncertain (u) or
inappropriate (I) based on available published data and
expert opinion. To date, initial and updated or in-progress
AuC have been produced for cardiac radionuclide
imaging (2005, 2009); echocardiography (2007, 2008,
2010); cardiac computed tomography and MRI (2006,
MDCvJ | vII (1) 2011 59

2010 CT); peripheral vascular ultrasound (2011); and
multimodality imaging (2011). The published AuC are
currently in an implementation phase. updated AuC
documents reflect advances in the clinical knowledge
base and more carefully refined indications. Desirable
outcomes include more rational cost-effective use. AuC
implementation tools may allow users and payers to
determine areas of over- and underutilization and
target areas where further clinical research is needed
(“uncertain” indications).
References
1. Patel MR, Spertus JA, Brindis RG, Hendel RC, Douglas
PS, Peterson ED, Wolk MJ, Allen JM, Raskin IE. ACCF
proposed method for evaluating the appropriateness
of cardiovascular imaging. J Am Coll Cardiol. 2005 Oct
18;46(8):1606–13.
Peripheral Arterial Disease: CTA or MRA?
Rey P. Vivo, M.D. a ; Selim R. Krim, M.D. a ;
Su Min Chang, M.D. b
aUniversity of Texas Medical Branch, Galveston, Texas; and
bMethodist DeBakey Heart & Vascular Center, Houston, Texas
Peripheral arterial disease (PAD) affects approximately
8 million Americans, and its prevalence is
expected to rise significantly with the aging population.
While intra-arterial digital subtraction angiography
(DSA) is regarded as the reference standard, lessinvasive
imaging modalities, including computed
tomography angiography (CTA) and magnetic resonance
angiography (MRA), are increasingly used
to establish the diagnosis, delineate disease severity,
and plan for revascularization interventions.
Recent advances in multidetector CTA have allowed
for improved spatial resolution, larger coverage area,
shorter scanning time, and use of lower amounts of
contrast. Relative to two-dimensional time-of-flight
imaging, three-dimensional contrast-enhanced MRA
has further improved diagnostic accuracy by markedly
reducing imaging time and enlarging the coverage
area. Compared to DSA, both MRA and CTA are highly
sensitive and specific in identifying hemodynamically
significant stenoses and in differentiating occlusions
and nonoccluded segments in all regions of the lowerextremity
arteries. Factors that need to be considered
when choosing an imaging test are local availability,
staff experience, and patient characteristics. MRA
does not require iodinated contrast or radiation exposure
and is therefore more favorable for patients with
contrast allergy and in younger patients who need
repeat testing. However, MRA uses gadolinium-based
contrast agents, which can be associated with nephrogenic
systemic fibrosis in patients with coexisting renal
insufficiency. Another advantage of MRA is its ability
for flow quantification. CTA, on the other hand, may
be preferred in individuals with pacemakers, metal
implants, and significant claustrophobia and in critically
ill/less-cooperative patients due to its very fast
data acquisition. In addition, there is more experience
using CTA in follow-up after stent placement.
60 vII (1) 2011 | MDCvJ

MetHodist de Bakey Heart & VasCular Center update
MDCvJ | vII (1) 2011 61

MetHodist de Bakey Heart & VasCular Center update
Sponsored by The Methodist Hospital System ® , Houston, Texas
62 vII (1) 2011 | MDCvJ

My yEARS WITH MICHAEL E. DeBAKEy
Louis H. Green, M.D.
In 1949, Dr. Michael E. DeBakey was 39 years old
and I was 26. I had served a year in a rotating internship
and another in a surgical residency at George
Washington university Medical School, but my wife
and I decided that we no longer wished to live in the
East. We wanted to return to Texas, and meeting a
young Michael DeBakey was impact enough.
I was one of his residents, and Dr. DeBakey
demanded that we be accurate, knowledgeable, and
well read; he expected us to know all there was to know
about the particular patient at hand. When working,
there was little to no small talk, although in a social
setting he could be very engaging. He was more than
kind and made me his first appointee to the recently
acquired vA Hospital in Houston.
I remember the great procedure that initiated what
became a medical wildfire. During the last week of
December 1952, Dr. DeBakey called Jeff Davis to set up
an emergency operation on a well-known candidate.
This man had been used as a demonstration patient
with a palpable abdominal aortic aneurysm. The procedure
of aortic resection with replacement homograft
was carried out by the team of Drs. DeBakey and
Cooley with assistance from the senior resident and me,
the junior resident. The homograft had been prepared
by the process of lyophilization, which was a freezedrying
method for having a graft in reserve, and with
the addition of saline to be prepared for grafting.
a triBute to MiCHael e. de Bakey, M.d.
The patient had a stormy post-operative course, survived,
and within two weeks had a thoracic aneurysm
resection with homograft replacement at The Methodist
Hospital. Post-operative care was assiduous, demanding
meticulous attention and care. Eventually, out of necessity,
it lead to the development of the Intensive Care
unit, which was ultimately adopted all over the country.
Things were never the same. Celebrities came from
all over the world as the Texas Medical Center was the
only place to receive this type of surgery. All roads did
lead to Houston — at least for the next 30 to 40 years.
The rest is history.
In the ensuing years, Dr. DeBakey was always
supportive of me. When I came to him with a medical
problem, I was berated for not bringing it to him
sooner. He was always quiet about this support, but I
knew that it was always there.
During my later years in private practice, I realized
what a fine and thorough training I had under
Dr. DeBakey. He had insisted that the resident do the
surgery and that the assisting staff serve as assisting
supervisor. He also felt strongly that producing a
skilled surgeon required more than observation and
assisting: the resident surgeon must bear full responsibility.
Dr. DeBakey will be remembered always in this
personal way, and at the same time I will never forget
his contribution to the advancement of medicine and
surgery.
MDCvJ | vII (1) 2011 63

My yEARS WITH MICHAEL E. DeBAKEy
Larry L. Mathis, M.H.A.
Founding CEO of The Methodist Hospital System
When I became president and CEO of The Methodist
Hospital in 1983, I was 40 years old; our worldfamous
medical statesman was 75, newly married,
and the father of a young daughter. Having worked at
Methodist for 12 years before being named CEO, I was
well acquainted with the legend that was Dr. DeBakey
as well as the apocryphal stories about him. But I hadn’t
had a personal relationship with him.
Dr. Michael Ellis DeBakey was the most prominent
physician of all time. He certainly put The Methodist
Hospital in Houston on the world map and continued
to grace it with his presence, wisdom, and guidance
until his death at age 99. He was in constant pursuit
of excellence and physician to kings, presidents, prime
ministers, movie stars, and to common men and women
who worshipped him. To me, he was everything the
legend said he was. And, he was human.
A delicate point in our relationship was reached
when it came time for Baylor College of Medicine and
Methodist to consolidate the leadership in our surgery
department. The problem: someone needed to convince
the world’s most famous surgeon to retire from
his chairmanship of Baylor for the good of the college
and the hospital. Since I was young and naïve, everyone
agreed that I should be the one to broach the subject. I
invited him to my office and began poorly. I stumbled
about, talking about life’s uncertainties, about change
being the only constant, and then I blurted out some-
a triBute to MiCHael e. de Bakey, M.d.
thing about death — that either one of us could be hit
by a bus. Dr. DeBakey said, “Larry, I think I know what
you are getting at. If that should happen, I would like to
say a few words at your funeral!”
I once escorted him to West Texas for a speaking
engagement. At the reception that followed, people
came up and reminded him that he had operated on
them, their parent, their sibling. It was an incredibly
memorable experience because he was treated with
such reverence and awe. It was like traveling with a
rock star — people just wanted to touch him.
When Methodist was contemplating restarting organ
transplantation, there was considerable opposition
from our medical staff because of their prior transplant
experiences (enormous disruption from constant press
coverage and the ultimate failure due to organ rejection).
Dr. DeBakey wanted to begin again; the medical
staff did not. The DeBakey of the apocryphal stories
could have demanded that we begin the program and
the medical staff be damned. He could have pointed
out, rightfully, that he put Methodist on the world stage.
But he didn’t. Instead, he graciously agreed that the
hospital needed time to come to terms with the
decision.
The fact that I was honored to lead the practice home
of the world’s most prominent surgeon will always be
among my proudest memories. I almost wish he could
have said a few words at my funeral.
64 vII (1) 2011 | MDCvJ

poet’s pen
WHY I AM NOT A BUDDHIST
I love desire, the state of want and thought
of how to get; building a kingdom in a soul
requires desire. I love the things I’ve sought —
you in your beltless bathrobe, tongues of cash that loll
from my billfold — and love what I want: clothes,
houses, redemption. Can a new mauve suit
equal God? Oh no, desire is ranked. To lose
a loved pen is not like losing faith. Acute
desire for nut gateau is driven out by death,
but the cake on its plate has meaning,
even when love is endangered and nothing matters.
For my mother, health; for my sister, bereft,
wholeness. But why is desire suffering?
Because want leaves a world in tatters?
How else but in tatters should a world be?
A columned porch set high above a lake.
Here, take my money. A loved face in agony,
the spirit gone. Here, use my rags of love.
—Molly Peacock
Molly Peacock was born in 1947 in Buffalo, New york and currently lives in Toronto. She is a past president of the
Poetry Society of America and the author of five collections of poems and a personal memoir as well as the editor
of two anthologies.
Reprinted from Cornucopia: New and Selected Poems by Molly Peacock. Copyright ©2002 by Molly Peacock. used
with permission of the publisher, W.W. Norton & Company, Inc.
MDCvJ | vII (1) 2011 65

W.L. Winters Jr., M.D.
in MeMoriaM
MICHAEL THOMAS McDONOuGH, M.D.
1928 – 2010
William L. Winters Jr., M.D.
Methodist DeBakey Heart & Vascular Center
Houston, Texas
In everyone’s life, there emerge a
importance of honesty, integrity, and
few who make a lasting impression.
compassion — the hallmarks of trust.
In my life, one such person was
Teaching by word and example, his
Michael T. McDonough, M.D., who
professional demeanor was impeccable.
died in Philadelphia on March 27,
After I left Temple university Hospital
2010, at age 82. A native of Brooklyn,
in 1968, our communication became
New york, Michael was educated at
less frequent but his exploits were
Fordham university and received
never far from mind through updates
his medical degree at Georgetown
from colleagues, especially Dr. Fred
School of Medicine, where he came
Bove, former chairman of the cardiol-
under the influence of Dr. Proctor
ogy section at TuH and the immediate
Harvey. He did a one-year intern-
past President of the American College
ship in Buffalo, New york, and
of Cardiology. His contributions to the
returned to Washington, DC, for his
medical residency, which he com-
Michael Thomas McDonough, M.D.
1928 – 2010
clinical lore of THu’s cardiology section
were pervasive for over 35 years.
pleted in 1958.
Michael and his wife, Mary, always
Our close connection began in 1960, when he entered wanted a large family. They were successful in rear-
the cardiology fellowship program at Temple university ing eight children, with all but one still living in
Hospital (TuH) in Philadelphia after serving two years Philadelphia today. His religion kept him very active
as a captain in the united States Army. I was a young in his church, and his love for children kept him busy
cardiologist on the faculty at that time, having just fin- coaching young sportsmen. By choice, he was a homeished
my own cardiology fellowship two years prior. body living for his family and for his profession. His
For the next eight years, we worked side by side — his youngest child summed it up best in a note to me: “I
first year as a fellow and the next seven as partners and think he practiced medicine as he parented: with com-
close friends in the cardiology section at TuH under the passion, love and patience. He was the best man I have
leadership of Dr. Louis A. Soloff.
ever known.” What warmer eulogy can there be? Many
Dr. McDonough’s positive attributes were numer- of our readers won’t recognize his name, except those
ous, but I especially enjoyed his warm personality and in the Philadelphia area. But there are many physicians
infectious sense of humor. I watched him mature into like Michael McDonough. you just have to look far for
a compassionate physician and intuitive teacher. His them. And when you find them, nourish and treasure
ability to find the right answers and communicate with them, because they represent what is best in practicing
patients was his forte. For a large man, he was among
the gentlest, and his focus never varied from providing
superb care for his patients and teaching doctors the
the art and science of medicine.
66 vII (1) 2011 | MDCvJ

To the Editor: After reading Dr. Berenson’s article
in the November 2010 issue of the Methodist BeBakey
Cardiovascular Journal, 1 I was reminded of an editorial I
wrote in September 1992 in Clinical Cardiology. Gerry
Berenson was the stimulus that led me to write that
piece. 2 I have included some excerpts from that editorial
relating to hyperlipidemia in children.
Facts
1. Children born in the united States have higher blood
cholesterol levels compared with the same population
in other countries.
2. Autopsy studies have shown fatty streaks and atherosclerotic
plaques in the blood vessels of young people
dying of other causes.
3. Blood levels of LDL cholesterol correlate with the
extent of early atherosclerotic lesions in young people
4. Children and teenagers with elevated LDL cholesterol
levels often have older family members with coronary
heart disease.
5. young persons with high cholesterol levels have persistently
higher levels when they become adults more
commonly than do children with low cholesterol
levels.
Who should be treated for hypercholesterolemia?
The answer to this question entails much more
than simply obtaining blood cholesterol or lipoprotein
studies. Obviously, the initiation of treatment in
an adolescent is a serious undertaking since one must
consider such things as the growth and development of
the patient — something that one doesn’t worry about
in the adult. It is my understanding that children and
adolescents whose total cholesterol and LDL cholesterol
(total cholesterol 170-199 mg/dl, LDL cholesterol 110-
129 mg/dl) should be treated first with diet; and, if that
does not result in a satisfactory result, drugs should be
instituted by the pediatrician/general practitioner or
lipidologist caring for the patient.
How can an adult cardiologist influence or practice
the prevention of coronary heart disease in the child
and adolescent?
Children and adolescents without symptoms rarely
come in contact with adult cardiologists. In fact, adult
cardiologists rarely see adult patients who have no
symptoms or other evidence of myocardial ischemia
such as a positive exercise test. Thus, it is difficult for an
adult cardiologist to advocate strategies to prevent the
letters to tHe editor
development of risk factors even in adults, since we don’t
have contact with the appropriate subset of the population.
However, the adult cardiologist does have frequent
contact with adult patients who have clinical manifestations
of coronary heart disease. In these patients, we are
treating them to prevent the end product of multiple risk
factors, i.e. myocardial infarction, unstable angina, atrial
and ventricular arrhythmias, sudden cardiac death, and
heart failure.
Should we not consider giving advice about prevention
for the offspring of these patients, e.g. prevention of
obesity, smoking, hyperlipidemia, hypertension, diabetes
etc.? By preventing the risk factors for cardiac disease,
we have the opportunity to educate our adult patients
that family members, especially the young, may be at
high risk for coronary heart disease if they develop the
usual risk factors. As Berenson has pointed out, we also
must educate our school teachers and society in general
about the potential implications of these serious risk factors
in our children.
C. Richard Conti M.D.
References
1. Berenson GS, Srinivasan SR, Fernandez C, Chen W, and Xu
J. Can adult cardiologists play a role in the prevention of
heart disease beginning in childhood? Methodist DeBakey
Cardiovasc J. 2010; 6(4):4-9.
2. Conti CR. Prevention of cardiovascular disease begins in
the young. Clin Cardiol. 1992 Dec; 150(12):877-878.
To the Editor: I very much enjoyed the issue dedicated
to cardiac tumor overview. My thanks to you and
all contributing authors for an excellent presentation of
this subject.
Manucher Nazarian, M.D.
Fort Worth, Texas.
To the Editor: I just received the most recent issue of
your new journal. It is full of interesting material, and
I especially enjoyed your piece on “The Elders.” There
were SO MANy elders that I had the privilege of work
with beginning in 1965.
My first recollection of Dr. DeBakey was in the late
60s, and I was in Kansas at my mother’s home mowing
MDCvJ | vII (1) 2011 67

her lawn on a hot summer day. My mother came to
the side porch and called to me that I was wanted on
the phone, long distance. She said that Dr. DeBakey
was calling for me, and she seemed quite excited. In
those days, most folks did not have gas-powered lawn
mowers, as you probably recall, so it was easy to just
leave the mower where I had stopped.
I went inside and answered the phone which was
mounted on a wall in the dining room and soon Dr.
DeBakey’s secretary connected me with the doctor. I
honestly do not recall now what he wanted but probably
something about his participation in one of the CME
program of the college or possibly something about
his participation on one of the ACC overseas Circuit
Courses.
I also recall being with him at Bob Eliot’s ACC program
in the Tetons in Wyoming. His wife at that time
and his daughter were with him, and he gave several
excellent lectures.
I always felt very privileged to have known him over
the years I was with the ACC. He was always most kind
to me and to our staff.
your “Elders” editorial was splendid. you, Charlie
Fisch, and many others, as elders of the ACC, were
indeed the “glue” that not only held the college together,
but took the lead in making the ACC the leading continuing
medical education specialty society it has
always been.
Bill Nelligan
Executive Director, American College of Cardiology,
Retired
Editor’s Note: The following letter to Dr. James B.
young is printed with the permission of Drs. Norman
M. Rich and James B. young.
I have thoroughly enjoyed your, “Tribute to Michael E.
DeBakey, M.D.”/Michael E. DeBakey M.D.: A Mentor
Remembered. Having you share your experiences
with Dr. DeBakey brought back many similar memories.
Obviously, we were both very privileged to have
known Dr. DeBakey over many years. As a mentor,
he always found time to be supportive. I have never
known anyone else who was as successful as he with
“multi-tasking.” I knew Dr. DeBakey’s name as long as
I can remember because my first hero/mentor was an
Arizona copper mining camp surgeon who had served
in World War I and who had multiple exchanges with
Dr. DeBakey during World War II. I met Dr. DeBakey
as an undergraduate at Stanford when he was visiting
with my second hero/mentor, Emile Holman, who was
still chairman of surgery at Stanford. Dr. DeBakey was
one of the most patriotic Americans I have ever known
and I have appreciated the privilege to be in attendance
for the final tribute to him at Arlington National
Cemetery in the mid summer of 2008. Thank you very
much and best wishes.
Norman M. Rich, M.D.
Leonard Heaton and David Packard Professor
uniformed Services university of the Health Sciences
The Norman M. Rich Department of Surgery
Guidelines for Letters Letters discussing a recent MDCVJ article or related research will have the best
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not duplicate other material published or submitted for publication. Letters will be published at the discretion of
the editors, and are subject to editing and abridgement. Letters should be submitted by e-mail to
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68 vII (1) 2011 | MDCvJ

6565 Fannin Street
Houston, Texas 77030
713-DeBakey
debakeyheartcenter.com
A B O u T T H E
METHODIST De BAKEy HEART & vASCuLAR CENTER
nonprofit
organization
u.s. postage
paid
liberty, Mo
permit no. 1180
The Methodist DeBakey Heart & vascular Center continues the groundbreaking work begun by
famed heart care pioneer, Dr. Michael E. DeBakey, and his associates, who developed many of today’s
life-saving techniques, tools and procedures at The Methodist Hospital. Located in Houston, Texas,
the Methodist DeBakey Heart & vascular Center combines research, prevention, diagnostic care,
surgery and rehabilitation services in a coordinated multidisciplinary program with one focus:
delivering compassionate, effective care and treatment to patients suffering from heart disease.