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The art of stopping the heart

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​The patient's heart is stopped. The lungs no longer pump air. But the patient is still alive. This is a typical scene inside an operating room in the midst of a cardiac procedure.

During an open-heart surgery at the Peter Munk Cardiac Centre, the perfusionist runs the heart-lung machine that is connected to the patient and will take over control of their heart and lungs.

While the surgeon operates on these organs, the perfusionist monitors the heart-lung bypass machine. A complex tubing system connecting the patient to the machine -- known as cardiopulmonary bypass -- diverts blood from the patient's heart while pumping it through the body. The machine also takes over the function of the patient's lungs and ensures the patient receives enough oxygen.

The machine and the perfusionists who operate it keep the patient alive during complex surgery.

"I think it's absolutely fascinating that one can do this — take over the function of the heart and lungs, take the patient's blood and pass it through all these artificial surfaces and pieces of tubing and give it back to the patient. Then they are able to resume function of their own heart and lungs afterwards, their brains are intact, they (can) survive the procedure," says Mindy Madonik, a perfusionist at the Peter Munk Cardiac Centre.

Madonik has worked as a Perfusionist at the Toronto General Hospital for 24 years. According to the American Board of Cardiovascular Perfusion, her trade has existed since the mid-1960s. Before that, physicians generally ran the heart-lung machines.

A lot has changed since then – and Madonik has been able experience many of these developments firsthand.

In her own words

"We are trained to respond to alarms, accidents or emergency situations that develop. There is usually only one perfusionist in the operating room during a procedure, and there are no other medical personnel in the room that can perform our role.

I started working at Toronto General Hospital in 1978 as a Respiratory Therapist. At the end of 1981, I began working for one of the cardiac surgeons as a research assistant. When he started up a surgery research lab, it was my job to learn how to manage the cardiopulmonary bypass (a heart-lung bypass machine).

I watched the perfusionists in the cardiac operating rooms, and they saved their bypass circuits (the machine's tubing) for me, which I rinsed out and took to the laboratory. I operated the cardiopulmonary bypass machine while the surgical fellows did their experiments. 

After eight years, I went to the Michener Institute in Toronto, ON to take the Perfusion course, (which was only offered as a post-graduate course to working nurses and respiratory therapists at the time). I was able to complete my education and work as a perfusionist.

I've been at Toronto General for 36 years. I've had various jobs in the hospital, but my 24th anniversary as a perfusionist in the operating room will be in September.

 The type of equipment that we use has changed drastically since I started. It's all been developed so that patient outcomes are much improved.

That's incredibly gratifying for me to see.

Sometimes, the cases that remain in one's memory are those where you've had a poor result or there's been some kind of an accident with the equipment. That's inevitable after you do so many procedures, nothing is perfect and sometimes equipment fails.

The challenge is to make sure your equipment is running optimally and to know how to react. You have to be proactive and anticipate problems before they happen.

There are also some patients whose recoveries we never forget and it is incredibly gratifying to have them come back to the hospital to visit, and see them healthy and happy. It makes all the hard work worthwhile, and I feel blessed to be able to play a role in their recovery.

Everyday is an exciting adventure and every patient is different. While we have routines in place, you can never count on anything being routine. You have to always be prepared for unforeseen events.

It gets your adrenaline going. There's still a lot of excitement to the job and if there wasn't I wouldn't be here still doing it."

A patient's perspective

Patients have also been touched by changing technologies in perfusion.

Dianne Sheflin-Armstrong is a Peter Munk Cardiac Centre patient who can attest to these technological advances. Her heart defect obliged her to have open-heart surgery in 1964 and in 1997 --- both times with the heart-lung bypass machine.

"(In 1964), I remember going in to the operating room and the heart-lung machine was huge. I thought it was a monster. It went ceiling to floor, wall to wall, and it had great, big, huge vacuum vents that went up and down."

Thirty-two years later, in 1997, Armstrong's experience with the machine was very different.

"When I went in to the operating room and I asked them, where's the heart/lung machine? Because of course, it wasn't this great big huge monster anymore. It was the size of a laptop!"

Technological advances have changed the landscape perfusionists work in, and like Madonik, they have also improved patient care.​

Did you know:

  • 1953 – first use of the heart/lung machine
  • 15 – perfusionists who work in the Toronto General Hospital​​
  • 1 – perfusionists per surgery (depends on complexity of the operation)
  • 4.5L – amount of blood that flows through a heart/lung bypass machine per minute
  • $350,000 – approximate cost of one heart/lung bypass machine​
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