A Young Heart in the Right Hands
Gabriel Mena, M.D., was busy in the operating room last May when a message popped up on his cell phone. The text came from a fellow doctor and friend in Houston who had heard about a young woman from Colombia, Mena’s home country, who had a rare heart condition and needed Mena’s help.
For months, Laura Caicedo, 23, suffered from a mysterious case of persistent chest pain and constant hypertension. Caicedo, who stands at 5’2″ and weighs 101 lbs., maintained a healthy lifestyle, exercised regularly and didn’t smoke. She had no history of health problems, such as diabetes or high cholesterol. By all accounts and appearances, Caicedo was healthy. But her blood pressure had skyrocketed to a dangerously high level, called a “hypertensive crisis.” Normal blood pressure ranges between 90/60 and 120/80, but a hypertensive crisis occurs when blood pressure spikes to 180/120 or higher. Caicedo’s blood pressure had reached an alarming 200/120.
Her heart was a ticking time bomb.
Doctors in Colombia were confounded by Caicedo’s medical condition for quite awhile. In March 2017, they finally diagnosed her perplexing problem: Caicedo had a tumor, called a cardiac paraganglioma, growing around her heart.
“I was really surprised and frightened at the same time,” Caicedo said through an interpreter.
Paragangliomas are rare tumors that grow in the nerve cells along the brain and spinal cord. Some types cause the body to produce excess noradrenaline and adrenaline, which affects various bodily functions, including heart rate, blood pressure and breathing. Left untreated, paragangliomas lead to heart attack, stroke and death.
Cardiac paragangliomas are even rarer. To date, no more than 50 cases have been reported. Given the location of the tumor and the high risk of surgical death associated with it, Caicedo’s doctors determined that it was inoperable and that they would continue treating her condition with medication. However, without surgically removing the tumor, they would just be delaying the inevitable: The growing mass would eventually engulf her heart and kill her.
Nonetheless, Caicedo and her family remained optimistic. Through a series of introductions, Caicedo learned about a foundation in Houston that might be able to help her and sent an email to a Houston acquaintance to act as a liaison. She and her family weren’t sure what to expect, but they hoped for a miracle.
They found one in Mena.
As an anesthesiologist in the department of anesthesiology and perioperative medicine at The University of Texas MD Anderson Cancer Center, Mena has experienced the highs and lows of treating cancer patients and building relationships with their families. He accompanies patients along their continuum of care at the hospital and helps facilitate recovery after surgery. It never fails to be a deeply gratifying experience, but several years ago, Mena could no longer ignore the restlessness stirring within him: He knew there was a population of patients who couldn’t afford to travel to Houston for care, let alone be treated at MD Anderson.
“Unfortunately, we in the medical center and many places, including MD Anderson, don’t have the possibility of taking care of [out-of-state] Medicaid children. It’s so hard for a mother or a father to have to tell their children that they have to perish because they don’t have any access to life-saving therapy,” Mena said. “It’s really heartbreaking. We are making great leaps in cancer care, but at the same time one of our missions is to eradicate cancer from the face of the Earth. That includes treating the rest of the world.”
Galvanized by his desire to help underserved and underprivileged children suffering from cancer, Mena in 2011 launched the United2Cure Children Foundation, a non-profit social impact organization that combines the surgical, oncological and pediatric expertise from institutions across the Texas Medical Center to deliver lifesaving therapies to cancer-stricken children. In addition, the foundation provides financial and psychological support for patients’ families.
In the best hands
When Mena learned about Caicedo’s condition, he was determined to help her and immediately forwarded her case to a team of thoracic surgeons at MD Anderson for review.
After studying her file, David Rice, M.D., professor of thoracic and cardiovascular surgery at MD Anderson, decided that the best course of action was to perform a heart autotransplantation, a procedure that would disconnect the heart from Caicedo’s chest, remove the tumor, reconstruct the heart, and then place it back inside her chest. The problem: Only a handful of surgeons in the entire world had the expertise to perform such a highly complex surgery.
Luckily, the top expert in heart autotransplantation for cancerous heart tumors—cardiac surgeon Michael Reardon, M.D.—was a stone’s throw from MD Anderson at Houston Methodist Hospital and agreed to lead the surgery.
On Aug. 15, 2017, Mena and his foundation flew Caicedo and her family to Houston to meet with Reardon and his team and introduce Caicedo to the first cardiac paraganglioma patient Reardon had saved many years ago. Reardon outlined the risks and benefits of the surgery. Yes, it was going to be invasive. Yes, it was high risk. And yes, cardiac paraganglioma patients had died on the operating table.
At this point, Reardon had only performed the surgery 15 times in his 40-year career. Caicedo would be his 16th patient for this procedure. Given the rate the tumor was growing and where it was located, Reardon said, Caicedo wouldn’t survive another year or two without the surgery.
“I was very nervous and anxious, but I put everything in God’s hand,” Caicedo said. “At the moment I went to Houston and had the appointment with Dr. Mena and Dr. Reardon, I immediately calmed down because I knew I was going to be in the best hands.”
Although Caicedo was initially apprehensive about the surgery, she had the rest of her life to look forward to. She was completing her degree in business administration from the Universidad de La Sabana and helping her father run the family’s interior design business. On top of that, Caicedo’s boyfriend of three years, Julian Cortes, had proposed to her. He stood devotedly at her bedside during her hospitalization from March to June 2017, holding her hand as doctors wracked their brains over her condition. When Caicedo was released from the hospital, Cortes promptly took her out for a romantic dinner and popped the question.
Her heart might have actually skipped a beat that night, but this time, it wasn’t because of the tumor.
“I was very happy and very excited,” Caicedo said. “I said, ‘Obviously!’ We’re still deciding on a date for the wedding, but we hope it will be between this year or the next.”
The surgery had to work.
Ideally, Reardon would have performed the procedure at Houston Methodist, but it would have been too expensive for the family and it would have cost the hospital an estimated $250,000 in operational and institutional fees not covered by insurance. Instead, Mena was convinced he could do it for a fraction of the cost.
Thanks to the philanthropic support of three donors (the Burk, Provenzano and Selber families), Mena and his foundation raised $30,000, part of which was used to fly Reardon and the anesthesia team to the Fundación Cardioinfantil in Bogotá, Colombia, to perform the surgery.
On the morning of Nov. 3, 2017, the day of the surgery, Mena, Reardon and Jessica Brown, M.D., a cardiothoracic anesthesiologist at Houston Methodist, landed in Bogotá. The trio met with Juan Pablo Umaña, M.D., lead cardiovascular surgeon and medical director of the Fundación Cardioinfantil, and members of the hospital’s medical-surgical team to review every detail of Caicedo’s surgery.
The operation was not only going to be life-changing for Caicedo, but for the doctors, as well. The surgery would be the first of its kind ever to be performed in Latin America, the doctors said. The team was about to make medical history.
By 8 a.m., Caicedo was prepped for surgery and wheeled into the operating room. After they put her to sleep, the surgeons were ready to begin. Reardon and Umaña made the initial incision down the length of her sternum and pulled back the layers of tissue to expose her heart. The two surgeons then placed Caicedo on the heart-lung machine for cardiopulmonary bypass, which maintained the flow of blood and oxygen during surgery and allowed Reardon to begin the cardiac autotransplantation.
They clipped Caicedo’s superior vena cava (the main vein that carries blood from the upper body to the heart), aorta and the pulmonary artery, effectively disconnecting the heart from the vessels leading up to the head. The only vein to which the heart remained tethered was the inferior vena cava, a large vein that carries blood from the lower and middle body, making the procedure a partial autotransplantation.
After partially removing Caicedo’s heart from her chest, Reardon and Umaña were able to expose the tumor, which measured 5 by 7 centimeters, about the size of a baseball. Unfortunately, the tumor had swelled to the point where it was pressing up against Caicedo’s aorta and pulmonary artery, compromising the left main coronary artery, which feeds blood to the heart.
Umaña looked across the operating table at Reardon.
“What are we going to do?” Umaña asked Reardon.
“We’re going to cut the left main [artery] in half,” he responded.
“Cut the left main in half?” Umaña repeated.
“That’s what you’ve got to do for this,” Reardon said.
Thankfully, the two surgeons had prepared vein grafts from Caicedo’s leg to bypass the split artery while they successfully removed the tumor. Using veins from the leg for coronary bypass is a rare technique that had only been performed on paraganglioma patients twice before, Reardon said.
“Sometimes the enemy of good is better, and this went very well. Somewhere in the next 10 to 15 years, she’ll probably need another operation just to redo her coronaries,” Reardon said. “But it’s a surgery that will carry with it a very low risk. It will carry a risk of less than 1 percent.”
Ten hours after the surgery began, shortly before 6 p.m., Reardon and Umaña completed sewing all the vessels back together, placed the heart inside Caicedo, restarted it to beat on its own and closed her chest. The team then carted Caicedo off to the intensive care unit for recovery.
“On the first day, I woke up with the happiness of being able to open my eyes again,” Caicedo said.
By 10 p.m., the team had removed her breathing tube and let her rest overnight. The next morning, Caicedo was sitting up, talking with her family and eating on her own.
Mena spared no time getting Caicedo back on her feet. As an expert in enhanced recovery after surgery (ERAS) protocols, a perioperative program designed to speed up the recovery process for surgical patients, Mena urged Caicedo to get up, walk around and eat. Unlike the conventional care protocol that encourages bed rest, a mounting body of evidence shows that patients who are mobilized shortly after surgery have better clinical outcomes, experience shorter hospitalization time and heal faster.
“The more you’re in the hospital, the higher the risk of complications, infections and pneumonia,” Mena said. “You’re in the bed and you’re not moving, so by accelerating her recovery, we allowed her to regain her strength, her muscles and her mental sharpness to allow her to go back to her loved ones safely.”
Mena kept a watchful eye over Caicedo’s postoperative recovery.
“He said that I am a very strong woman, that I was capable of everything, that little by little I had to walk and make an effort. He had words of motivation, of love, all the time,” Caicedo said. “For me, he has been an angel. I learned that the limits are only in the head.”
Mena’s encouragement, coupled with Caicedo’s self-determination, paid off. By the second day, Caiedo was out of bed and walking around. A week later, she was discharged from the hospital.
“Now, I feel perfect,” Caicedo said, months after her surgery. “My recovery has been spectacular. I feel very good. I have my normal life again.”
‘We all leave our egos behind’
For Reardon, who trained under legendary heart surgeon Denton Cooley, M.D., at the Texas Heart Institute, Caicedo’s surgery was a master class in one of the rarest and most complicated heart surgeries.
“When I first went down there, [Umaña] said, ‘You can do this.’ I told him, ‘No, you can do this, and I’ll help you. I already know how to do this. Let me teach you, so the next time this comes up, you’ll know how to do this,’” Reardon recalled. “It’s a teaching moment for everyone concerned. I always learn when I do these things. You always learn when you watch other people and listen to them.”
Reardon has performed close to 300 cardiac tumor and 116 primary cardiac sarcoma surgeries, and continues to run several clinical trials and research initiatives. But he isn’t interested in his own statistics.
“When I finish my career, nobody is going to care how many papers I wrote. They’re not going to care about how many research trials I ran. They’re not—and I’m probably not—going to remember,” Reardon said. “What I’m going to remember, though, are the people I met, the friends I made, the places I went. When I get to go do something, like go down to Bogotá and operate with an excellent team like that, with my friends from MD Anderson, the memories that this creates are something that’s going to be around forever.”
The Texas Medical Center has long been lauded as the nexus of world-class patient care, medical innovation and research, boasting nearly 60 member institutions. For Mena, the heart of clinical success and medical advancement is collaboration, not competition.
“It’s not about MD Anderson. It’s not about Houston Methodist. It’s about Laura [Caicedo], a girl who had cancer,” Mena said. “We all leave our egos behind. We all come together to collaborate, give the very best scientifically and our expertise to deliver this world-class care. We don’t care about anything else, and I think we need to help foster that culture in our Texas Medical Center. This is the mecca of medicine in the world, but we still have some distances to go.”
With United2Cure Children, Mena hopes to harness the best and brightest minds in the Texas Medical Center, like Reardon, to help patients who otherwise couldn’t afford cancer treatment. Since its inception, the foundation has sent experts from the Texas Medical Center to help approximately 20 patients across the country and South America. But Mena has his eyes fixed on a bigger goal. Instead of flying experts to other locations, he plans to treat more patients by bringing them to the medical center through his foundation.
He admits it’s an ambitious plan, but he’s up to the challenge.
“It’s a big philanthropic effort, but we can do this,” Mena said. “We are here. We have a mission. We have to take care of people who need our help.”