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Sitting numbly in that dark room, I felt as if I were getting a glimpse of how I was probably going to die.
Listening to family lore, I grew up with a fear of the heart as the executioner of men in the prime of their lives.
If life is a continuous struggle against the inexorable march of entropy, then the heartbeat is at the core of that conflict. By purveying energy to our cells, it counteracts our tendency toward dissipation and disarray.
the heart is self-sustaining.
We associate the heart with life because, like life itself, the heart is dynamic. From second to second, and on a macroscopic scale, the heart is the only organ that discernibly moves. Through its murmurings, it speaks to us; through its synchronized contractions, it broadcasts an electrical signal several thousand times more powerful than any other in the body. Over the centuries, disparate cultures have viewed the heart as the source of a life-giving force that was to be culled or harvested.
Patients who once might have died of heart disease now must live with it,
Ironically, as we become more adept at treating heart disease, the set of people who are ill with it is growing.
No other organ—perhaps no other object in human life—is so imbued with metaphor and meaning.
And though the house has no intrinsic meaning, it carries meaning because of the meanings we attribute to it. The heart was once considered the center of human action and thought—the source of courage, desire, ambition, and love. Even if those connotations are outdated, they are still deeply relevant to how we think about this organ and how it shapes our lives.
By then, darkness was approaching, replacing the jaundiced sky.
Then, with her usual scolding sympathy, she said, “You should do a different experiment, son. Your heart is too small for this.”
Even the word “courage” derives from the Latin cor, which means “heart.”
The richness and breadth of human emotions are perhaps what distinguish us most from other animals, and throughout history and across many cultures, the heart has been thought of as the place where those emotions reside. The word “emotion” derives from the French verb émouvoir, meaning “to stir up,” and perhaps it is only logical that emotions would be linked to an organ characterized by its agitated movement.
When Barney Clark, a retired dentist with end-stage heart failure, received the first permanent artificial heart in Salt Lake City, Utah, on December 1, 1982, his wife of thirty-nine years asked the doctors, “Will he still be able to love me?”
Over the years, I have learned that the proper care of my patients depends on trying to understand (or at least recognize) their emotional states, stresses, worries, and fears. There is no other way to practice heart medicine. For even if the heart is not the seat of the emotions, it is highly responsive to them. In this sense, a record of our emotional life is written on our hearts. Fear and grief, for example, can cause profound myocardial injury. The nerves that control unconscious processes, such as the heartbeat, can sense distress and trigger a maladaptive fight-or-flight response that
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Takotsubo cardiomyopathy is the archetype of a disease that is controlled by interactions between the emotions and the physical body. In no other condition do the biological and metaphorical hearts intersect so closely.
What these deaths had in common was the victims’ absolute belief that there was an external force that could cause their demise and against which they were powerless to fight.
life-threatening stress unleashes an autonomic storm on the heart that has both sympathetic and parasympathetic components.
morbidly serene visage.
faintly hominid in appearance,
It was a fascinating exercise, a reminder to us aspiring doctors that even as we tried to figure out how our cadavers had died, we should not forget to think about how they might have lived.
The most interesting thing about my nameless cadaver, I realized, was not why he had died but rather how he had managed to live for as long as he did, when for others the journey had ended so abruptly.
In an indelible pearl of wisdom, our anatomy professor told us that a cardiac anomaly can sometimes cancel another anomaly, if only incompletely. For instance, if a valve does not open, blood must find a path around the obstruction. Such a detour—a hole between chambers, for example, or an anomalous connection—can have devastating consequences in an otherwise normal heart, but in a diseased heart it may actually attenuate the pathology. In the human heart, he said, two wrongs can make an imperfect right.
From that point on, I thought, every careless mistake I might make in the hospital would be a slap in his face, every success a tribute to him, my first patient. He had given himself freely—wholeheartedly—and now I had to give him back and leave him to restful peace.
“In the end, cardiology is mostly a problem of plumbing.”
The heart can kill quickly, without warning, faster than any organ, which inspired fear in even the most seasoned doctor. And so a fellowship in cardiology was like entering an exclusive club, a club that incredibly had decided to take me as a member.
he did as much as any doctor in history to demystify the heart and advance the notion that it was a machine that could be repaired.
“Since ancient times, the heart has been regarded as ‘noli me tangere’ [but] with [heart surgery] the last organ of the human body has now fallen to the hand of the surgeon.”
The risk of death among some patients starts at around 20 percent and gallops in 1 or 2 percent increments per hour.
Holding forceps and a scalpel, Shah cut open the silvery pericardium. The heart was dancing wildly, an incredible sight.
Never had the boundary between life and death seemed so thin.
Though an artificial kidney was developed with relatively little fanfare, the heart occupied a special place in the popular imagination. How could a man-made machine replace the organ that houses the soul?
In short, they were cardiac cripples, their existence doomed, their prognosis worse than many childhood cancers.
Today, patient autonomy and shared decision making are mantras in the hospital, ethical imperatives that supersede all others, including beneficence. But the situation was very different in the 1950s, when doctors were more apt to act without what we would consider informed consent. Medical paternalism was rampant, but it would be a mistake to think of Lillehei as authoritarian. By all accounts, he was an unusually compassionate physician, having been a patient himself. As a patient, he knew the vulnerability that comes with illness. He knew on a visceral level how patients look to their
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How to protect patients while doctors learn is a conundrum still faced in all areas of medicine.
They argued that surgeons with children’s lives in their hands should not take on more than they could handle. How then, surgeons responded, do we innovate? For a new technology, there is no opportunity for rehearsal. For an innovation to benefit patients, there has to be a first time.
Tense colleagues whispered that Lillehei was a “murderer”; no one could stomach seeing little babies die. In response, Lillehei reportedly said, “You don’t venture into a wilderness expecting to find a paved road.”
In the end, history has judged his work to be a success.
The machine was a massive technological leap, but it required an equally large conceptual jump: that blood could be circulated and oxygenated by a machine; that in the end there was nothing fundamentally special about the human heart.
his belief that elderly patients with less time left to them have a greater will to live than younger patients.
“Our rule is not to operate until the patient, as far as is humanly possible to judge, no longer has any chance of returning to life.”1
And so I came to think of my cardiology training as being on dual tracks: learning about the heart, obviously, but also what was in my heart—what I was made of—at the same time.
Procedural comfort eventually lent a certain balance, confidence, to my fellowship experience. For the first time that I could remember, physical action alleviated my anxiety, providing me with a zone of calmness in which to operate.
No doubt he wanted to expunge the heart of its emotional connotations. But the idea that the human heart was just a pump, like an animal’s, was still anathema.
“The subject had progressed too far,” he wrote, “and when I considered it objectively I was certain I’d never catch up.” He decided “it was more honest to content myself with the role of leading fossil.”
(As is so often true in medicine, treatment outpaced understanding.)
And so, acculturation, they declared, is a major risk factor for coronary disease in immigrant populations.
“The heart attack is so common among professional people, executives, and men in public office that it has become almost a status symbol.
Today a massive amount of epidemiological data associates heart disease with chronic emotional disorder—or disruption of the metaphorical heart. For example, individuals in unhappy marriages are at a much higher risk for heart disease than those in more joyous unions.
Medicine today conceptualizes the heart as a machine.
