In January 2021 I spoke to the Ostler Club of London about the developments in paediatric cardiology and interspersed it with poetry from my collection Litany of a Cardiologist which followed the same thread.
William Harvey described the circulation of the blood in 1628. His discovery was initially rejected, and later thought to be of ‘no clinical significance’. I would like to set the record straight with this poem:
Before the 1960s there was little progress in the surgical treatment of heart conditions, particularly in children. In 1961 the first successful open-heart surgery was carried out on child of 3 years. However cardiac surgery on children (especially babies) lagged behind that for adults.
Transposition of the Great Arteries is a heart condition in which the aorta arises from the right pumping chamber (ventricle) and the pulmonary artery from the left ventricle.
Before the baby is born, connections within the heart allow the blood to mix, but soon after birth these close. Blood with low levels of oxygen returns from the body to the right-sided pumping chamber (ventricle) and is pumped straight back to the body. The baby becomes intensely blue from lack of oxygen and desperately ill.
In 1965 Dr Rashkind developed cardiac catheter procedure to create a hole between the collecting chambers in the heart (the atria) to mix the blood. It must be done soon after the baby is born. This temporary procedure is still done today. My poem Disordered Heart describes this procedure.
I began work as a doctor on 1st January 1971 (just over 50 years ago) and my first cardiology post was in 1972. By that time various heart operations were being performed in children, including closing holes within the heart and replacing heart valves. However, the risk of open-heart surgery in children remained extremely high.
Some children had such complex heart conditions that they could not be operated on in the 1970s. As a result of damage to lung arteries, there was nothing that could be done for these patients, not even a heart transplant, when they were older. My next poem is a tribute to the indomitable spirit of such patients.
When I started working in cardiology, I quickly realised that I wanted to become a paediatric cardiologist. Initially I trained as a paediatrician at Red Cross Children’s and Groote Schuur Hospitals in Cape Town. I worked briefly as a registrar Christian Barnard in 1975 who taught me that the care of children in the days after surgery can be almost as important as the surgery itself.
Heart surgery in children continued to improve and surgeons began to wonder what could be done for a child who had only one pumping chamber. It was clear that the functioning ventricle must pump to body. The veins coming back from the body are connected to the lung arteries so that blood can flow into the lungs to provide oxygen. Children undergo a series of operations compensate for what was not there.
My frustration shows in the poem, Cyanotic Child. I wished it were possible to re-create chambers that were missing when the child was born. Paul Klee was an artist working in the first part of the 20C. He was famous for his childlike images and included hearts in many of his pictures. This poem compares his idea of a heart to mine.
Operations were available for children with Transposition of the Great Arteries (the condition I mentioned before) but they did not correct the problem. In the 1990s surgeons began performing the arterial switch operation. It was an extremely complicated operation for a child to undergo and it had to be done in the first few weeks of life.
Although I was not a surgeon, I was often in theatre, particularly when one of my patients was undergoing an operation. My poem, Open Heart, is my memory of a child undergoing the arterial switch operation.
In the 1990s it became possible to make a diagnosis of congenital heart disease before birth. This was part of my work as a paediatric cardiologist. I would then discuss with parents what that would mean for a child after birth. This is reflected in my next poem.
Echocardiograms were used to make the diagnosis of heart disease in children and this could be difficult, particularly in babies. There are huge variations in heart structures in children with heart abnormalities. Using two dimensional scans, it can be difficult to see how each structure relates to others especially in extremely ill infants.
Surgeons operation on tiny hearts and they rely on cardiologist to supply every detail.
I was remembering the burden of making such difficult decisions (often with the pressure of an urgent operation) when I wrote this next poem which won the Hippocrates Prize for Poetry and Medicine in 2016.
In the 21st Century, results of many types of treatment improved for children with complex heart conditions including successful heart transplant. This brings me to my next poem.
We occasionally see images of a child on the television connected to a mechanical heart machine while awaiting heart transplant. My poem, Ventricular assist, is written in the voice of a parent. I seldom write in this way, but I have sat with parents during the agony they endure at such times. I wanted their voice to be heard.
Procedures are occasionally attempted if a foetus has a condition which is progressing before the baby is born. An example of this would be a foetus with a narrowed valve. If this valve could be stretched open, the heart could continue to grow and the baby would have a less serious heart problem at birth. This poem is Addressing a Foetal Heart.
While looking forward I will also look back. Research for my medical doctorate was about children who had a narrowed aortic valve. In my reading, I came across writing by Leonardo da Vinci who described how the aortic valve works in about 1513.
My final poem is the title poem for my book. After I retired, I had a real hunger to speak the medical words I had used at work. On some days it was like an ache in my mouth. I thought about the words I used when discussing a child’s condition with colleagues and how those words changed when I was speaking to the parents of the same child.
The first line of each two-line verse contains the words I used when discussing a child with colleagues. The second line contains words with the same meaning that I used when speaking to that child’s parents.