friday night essence

Respond to Meeting Level 1 Integrations?

1. Ernest Feiler says:

   January 12, 2013 at 3:44 pm

   Thanks, Joan!
   The value creation I have been involved with is substitution of alternative blood flow channels for coronary artery blood flow that is decreased, as clearly shown by infrared imaging. Since the heart has only a single blood supply, in contrast to many other organs that have two or more, the margins between decreased blood flow and the rest of the heart is clear and immediately recognizable. Most surgeons prefer gray scale instead of color scale since this gives an easier image for orientation in the operative field, and I agree with this.
   In attempting to understand the essence of this alternative blood flow the first step was to measure the flow through a channel from the inside of the heart pumping chamber, or ventricle. My 10 second miracle took a little longer (!) but by cutting a syringe transversely to its long axis, and using a lathe to leave no sharp edges as a saw would, and then super-gluing the chamber end of the forward section of the syringe to the inside of the heart, it was then possible to connect the narrow end of the partial syringe to an intact syringe filled with permanent ink, or saline solution, etc. This was done on a fresh pig heart, because pigs are the accepted model for research on human coronary arteries.
   The next step was to find how much blood or other fluids could be flowed through the channel, which was 0.8 mm in diameter. Contrary to expectations, this tiny channel flowed a ml. of saline per second, a sign that there had to be a large “run off bed” or system of interconnected vessels to handle such a large volume. Normally one would use Methylene blue dye, which does not harm tissues and is therefore called a vital dye. It washed out, since it is water soluble, and we saw nothing! I tried to find indelible ink, and was able to get some last year. By flowing this through the channel, then freezing the heart segment with dry ice and then cutting it transversely to its long axis, it was possible to see what I called a cylinder of distribution, COD, that extended the entire length of the channel from the outer surface of the heart into the ventricle. The smallest radius of this rather irregular area was the same at all levels of cutting, and corresponded to the infrared picture we obtained on the surface of the heart. We used this radius to construct circles which were uniformly 15 mm. in diameter. We now had a measured method of spacing the channels, never possible before. By pouring cold water over a live heart, and temporarily occluding one coronary artery with a padded tourniquet, we could see the rapid rewarming of the heart surface by flow of the warm blood, while the area served by the occluded artery remained cold, giving a sharp contrast that defined the run-off bed of that artery. Earlier work had determined that a temperature difference of 2 degrees C. was all that was needed to show a good margin of delineation.
   We now had two things that had never been discovered before, a measure of the run-off bed into which the channels had to be placed, and the method of determining the optimal spacing of the channels do that no area of heart muscle was left without blood flow when the artery was totally occluded.
   The next step was to test this, for which we used live pigs operated on at the Colorado State University Veterinary School, one of the premier Vet Schools in the country. We outlined the run-off bed with a tissue pen, then created the channels by pushing a specially designed cannula through the heart muscle into the ventricle, and letting the suction remove the core and such any possible tissue fragments as well so they would not be carried to distant sites and cause small vessel obstructions. The method of testing the effectiveness of the channels required no ten second miracle – we simply tied off the coronary artery permanently so that there was no further coronary blood flow into the downstream heart muscle. There was no change in the blood pressure, the oxygen content of the blood, the electrocardiogram or the calculated output volume of the heart. After four hours of stability we euthanized the pig, and sent the heart to pathology. There were no microscopic areas of damage to the heart muscle, and the oxygen content of the muscle cells was normal, tested by a special stain of the slides.
   We did the same thing on another pig that was awakened after surgery and euthanized at seven weeks. His heart was divided into three tissue blocks and sent to three independent pathology labs, again with 100% successful findings, from all three labs.
   I don’t want to wear you out! Suffice it to say that the remaining ten second miracles suggested that we overlap the COD’s and were able to show that they shared their flow; automatically circumventing any scar, etc. obstructions in the heart muscle; that the single cell thick lining of endothelial cells in the channels is the same as the walls of the capillaries that do not close a the result of arteriosclerosis while the multi-layered walls of arteries and veins that are used for bypass grafts do close, 5% for arterial grafts and 22% for vein grafts. Therefore it can be expected that in contrast to bypass graft surgery as is now being done, the channels will have perfect results because they will not occlude at a later time, and so forth.
   Please let me know what you think, and if this qualifies for going on to the next step! Thanks! I am in awe of Mark Hamilton who once wrote me that he believed I was a maverick. As usual, he was right, but I have no idea how he found that out! Using mechanical channels such as we use was dropped in the ’60s! He is an incredible man! And you must be incredible too, to be one of the mentors! Thanks for everything! Ernie

2. Ernest Feiler says:

   January 12, 2013 at 3:50 pm

   Thanks, Joan! I will await your comment. Ernie