The golden aura of the rising Sun lit up the eastern sky. The start of another day in his life, he awoke in eager anticipation of events which might unfold. In all his six years, he had learnt not to talk loudly and not to ask too many questions. The questions were there, burning within him. He somehow knew he would have to find the answers himself. The school was a friendly place if he respected his boundaries. No transgressions beyond severe drawn lines were allowed. His skin was dark, and he was in the colored section. Within his limits, he was tolerated. His teachers were affable, even encouraging some of his questions. Home was a warm, secure cocoon with his mother cooking tirelessly to feed her hungry family. His father tinkered with wood and used to carve beautiful, sturdy pieces of furniture. His ambition was to apprentice his son in whom he saw a distinct spark of creativity. As the boy grew up, he began slowly and cautiously learning his father’s trade. His keen ability to foresee knotty problems while carving and the uncanny ability to solve them impressed his father and several others.
He was a keen and astute observer who imbibed the subtle nuances of technicalities, making his pieces a cut above the rest. From school he gleaned lessons, especially science and mathematics which intrigued him. Graduating from school, he built his repertoire of facts upon which he based his creations. He could not study further due to financial difficulties of his family. He continued to apprentice his father in his work yard. As incomes dwindled, he had to look out for a job and found one as a research assistant in a scientific laboratory associated with the prestigious university. Here, he helped in animal experiments, using anesthesia on pigs and dogs.
Several experiments were on, especially on canine and porcine hearts. These interested him and he would spend hours helping and learning by these. It was here that way back in 1944, another colored person Vivian Thomas had helped evolve the surgical technique of the Blalock-Taussig shunt. He had read all about it and felt proud about Thomas’ achievements.
Pathological and clinical studies in humans had demonstrated early alterations in left ventricular topography in approximately one-third of patients who died due to acute myocardial infarction or heart attacks. These topographic alterations, referred to as expansion of the injured area of the heart, which was characterized by dilation and thinning of the. Such changes had been observed to appear clinically as early as 3 days after heart attacks and were seen to progress over days to weeks. This process appeared to be associated with deterioration in cardiac function and increased deaths which might be due to mechanical complications of the heart attack like cardiac rupture and aneurysm formation ( persistent bulge). Studies in humans had suggested that certain features, like involvement of all the layers of the cardiac walls and larger size of the heart attack, might be determinants of the development of expansion. To determine the factors responsible for this expansion, experiments were ongoing on canine hearts. They proceeded by ligating one of the coronary arteries ( arteries which supply blood to the heart muscle) After creating a heart attack thus, the animals were killed, and their hearts studied. An expansion index was determined, which required precise measurements in a dead heart which was not firm but flaccid.
He was very keen and his measurements in the canine hearts were precise making the results greatly accurate. Microscopic examination suggested that heart attacks not involving all the layers of the cardiac walls did not expand, while majority of heart attacks with involvement of all layers of the heart demonstrated significant expansion. If early thinning and dilatation did not occur, the process of cardiac reshaping which was a natural process, resulted in a scar formation but with preserved left ventricular contour. Preservation of this contour for any infarct size was advantageous. Dyssynergic areas increased the ventricular volume and diameter and wasted a large part of the total work of the heart, placing an increased burden on the remaining healthy heart muscle. Expansion of a heart attack further increased the functional size of the diseased cardiac muscle. This process of expansion, cardiac reshaping which eventually led to detrimental cardiac failure and even death was an unending dilemma.
His interest was ignited in studying the properties of the cardiac aneurysm.
When the heart muscle in an aneurysmal area functioned improperly or had been replaced by fibrosis, local tension development during cardiac work was restricted or absent. Cardiac work would then fall. So, he deduced that in order to maintain constant work efficiency, heart muscle fibers located far away from the aneurysm must increase their extent of shortening. This led to heart dilatation. These concepts were new to him and puzzling. The science classes and math that he had learnt in school were re-kindled in his thoughts.
With the surface area of an aneurysm being 20% to 25% of the total heart volume, the normal portions of the ventricle had to dilate to maintain effective cardiac work. This was a concept proposed by one of the cardiologists. He began thinking about whether the shape of the aneurysm had any effect on cardiac work For this he approached a mathematician with his idea. On computing aneurysm shapes of circles and rectangles it could be mathematically deduced that with a rectangular aneurysm shape, the ratio of percent normal muscle to percent inactive/ dead muscle was greater than a circular aneurysm shape. But, from his observations on canines, he had noted that aneurysms generally did not correspond to any geometric shape, least of all being rectangular! He did not think more of this as it struck him as being unrealistic. The cardiologists too thought of it as a ‘mathematical observation’ and nothing else.
It was an era of breakthrough cardiac surgeries. There were several cardiac surgeons who tried several surgical means to alleviate congestive cardiac failure. Left ventricular reshaping or restoration surgeries were being performed at several centres. There was an evolution of the surgical technique from linear repair which entailed resection of the aneurysm followed by bringing the excised borders of normal myocardium together and suturing the borders. This gave way to the geometric repair by using a synthetic patch to exclude the aneurysmal area from within the cavity of the heart. It was indeed a very onerous task to preserve a normal ellipsoid cardiac contour following surgery and prevention of further dilatation long after surgery.
A young and dynamic cardiac surgeon who dared operate the most complicated surgeries, visited his research lab. He was impressed by the various studies and experiments being conducted. On discussing the problem of cardiac restoration procedures for aneurysm, his keen eye caught the mathematical deductions done by a mathematician in consultation with a coloured research assistant. He then decided to use a rectangular prosthetic patch instead of the circular one he had been thus far using. To his pleasant surprise, he found the heart being restored to a more elliptical shape with its twisting motion returning when the heart resumed beating. These patients also had a better long- term outcome several years after surgery.
The fire ignited in a research laboratory while performing canine experiments helped resolve a complicated dilemma in the operating room. This went on to be a lasting solution to a vexing problem and helped improve lives of several patients. Several game changing solutions often emerge from humble beginnings. The person who discovers them tends to remain unknown and unsung, which is a sad paradox.