“I’m a little groggy,” said James, a retired bank president from Ashland. “I don’t remember a whole lot.”
The 67-year-old identical twins were mirrors of relief: one man standing and smiling; one man lying and grinning. The blood was flowing unencumbered to and from James’ heart again.
“I’m glad I came,” Jerry said, explaining James’ wife has her own medical condition and couldn’t make it.
From Jerry came the ultimate self-diagnosis: “I’m still here,” he said.
James Ogilvie was in a room off of what’s commonly referred to as “the cath lab.”
Officially, it’s the cardiac catheterization laboratory at Essentia Health-St. Mary’s Heart & Vascular Center in downtown Duluth.
In July, just a few weeks before Ogilvie’s procedure, the cath lab earned national recognition from an independent, physician-led organization called Accreditation for Cardiovascular Excellence. Only 21 other hospitals in the country have earned such a nod from ACE. Essentia Health-St. Mary’s was the first Minnesota hospital to be granted the status. Through January, the facility had seen more than 90,000 patient visits during its existence dating back to the early 1980s.
“The commitment to excellence in what we do is what benefits our patients the most,” said Dr. Wilson Ginete, the interventional cardiologist who performed Ogilvie’s procedure. “It’s an honor to know Essentia Health-St. Mary’s Heart & Vascular Center is on par with the best in the country.”
A tour of the facility given to the News Tribune included a firsthand look at Ogilvie’s procedure. It’s always impressive to watch experts perform expertly, and this trip inside the cath lab was no exception.
There is a quiet and confident calm among the staff there, despite the life-and-death stakes involved in every procedure. Still, their extreme competence doesn’t hide their own sense of awe.
“It’s a miracle,” said Karen Majerle, a radiology technician, of the catheterization process that began many years ago with simple balloon angioplasties opening clogged arteries. The procedures evolved to include using stents to keep arteries open, and are still evolving for use in other areas of the body — not just the heart.
The equipment is space-age in its state-of-the-art-ness, with some of the more flexible stents featuring actual welds the size of needle points. Other stents are laser-carved from tiny but solid tubes made of stainless steel and other alloys. The balloon used at the end of a catheter can be inflated to 300 pounds of air pressure per square inch, meaning a synthetic film as thin as a few layers of skin can hold many times more air pressure than your car tires.
These are all details readily available from Mark Johnson.
He is the manager of the cath lab and the day’s tour guide. He’s encyclopedic in his knowledge. He’s also affable, which elevated the tour from just a look-see to a full-blown lesson. He’s been a part of thousands of procedures and has scheduled thousands more. The scheduling can be tricky. There’s no accounting for heart attacks and other emergencies and, while the routine catheterization procedure “can be pretty quick,” he said, each catheterization has potential to present its own hurdles.
“It’s soup to nuts,” Johnson said. “You get what you get.”
The tour starts next to a windowed storage locker inside a vacant lab. There are seven labs — three for vascular catheterization and two each for electrophysiology and surgery. Inside the storage locker are catheters, dozens of them, hanging like timing belts on an auto parts retail rack. There are diagnostic catheters. There are catheters that, once inside the arteries, serve as tubes for secondary catheters to travel through. There are pigtail catheters that search the heart’s chambers with a curled tip and balloon catheters capable of carrying stents to their destination.
Johnson held out a catheter, a few feet long, as if he were displaying a tie.
In the downtime before Ogilvie’s procedure, Ginete visited in his office with another patient. Technicians prepped the room while Ogilvie lay on the operating table in the early stages of conscious sedation. Even so, Ogilvie was asleep, which isn’t unusual, Johnson said.
“Stay away from our blue; that’s the sterile part,” Majerle said once inside the lab, where a blue towel covered a gleaming stainless steel tray that featured sterilized instruments.
Ogilvie rested under a giant X-ray machine attached to a C-arm. The C-arm is capable of rotating on a half-circle around the patient. The X-ray machine provides constant, real-time images to the doctor and staff on monitors throughout the room. A dye, heavier than blood, is injected into the patient through the catheter. The dye is picked up by the
X-ray and allows it to create the black and white images as it courses through the arteries with each pump of the heart. The total image, then, features the skeletal system — vertebrae and ribs — to go with pulses of dye that illuminate the circulatory system Ginete will use as a highway to the heart. The heart itself doesn’t show up on an X-ray, but it’s most definitely there, beating and revealing itself in the arteries and vessels that surround it.
“A shadow image of the heart,” Majerle called it from her place behind banks of protected glass and computer screens.
The lights inside the lab went on and off throughout the procedure. They were off when Ginete was working while watching the monitor. They were on when Ginete needed to see something away from the screen, like his incision and subsequent insertions of catheters into Ogilvie’s femoral artery.
The insertion area near the right groin “has been the gold standard in the United States for 20 years,” said Johnson, who later explained that catheterization is now using the wrist and neck as entry points.
The doctor and his technician wore lead flak vests to protect them from the X-rays. They used an economy of words between them. The work presented itself with elements of the mundane, but only because Ginete and company are so fluid and in control. There was one point in the procedure when the artery containing the catheter had a spasm, requiring a dose of nitroglycerin to settle it. There is another point in which Ogilvie became hypotensive. The low blood pressure was treated with a dose of saline solution, Johnson explained afterward.
Attached to the catheter is a manifold. Anything that goes into the catheter — saline, dye, nitroglycerine — is at the doctor’s fingertips.
The procedure took less than half an hour. A physician like Ginete is capable of a handful of such procedures in a day, Johnson said.
‘A stent sandwich’
Outside the cath lab, Johnson pointed to one of the nearby labs. It’s a short sprint out a door from the hospital’s helicopter pad.
“We do a lot to shave a few seconds,” Johnson said. “Time is muscle.”
For Ogilvie, this was his second stent. He had begun feeling weak and short of breath, the same symptoms that preceded his first procedure two years ago. Restenosis, a repairing of an initial stent, is not uncommon, Johnson said. Ginete’s probe with the first catheter found that the blockage was in exactly the same spot Ogilvie had addressed by a physician previously.
In short order, Ginete determined that a second stent, 26 millimeters long, was required to bolster the artery that appeared in the X-ray as a thinning collapse — like a two-lane highway suddenly down to a single lane.
The new stent was placed inside the original stent. Ginete inflated the balloon to set the stent inside the original one. The balloon was then deflated and removed, leaving behind what’s labeled in cath lab terms as “a stent sandwich,” Johnson said.
“There’s more to it than what you see,” said Ginete, who described the precision of the procedure as being a result of the intense preparation. It starts with selecting the right patient, he said, someone who is likely to be well-served by a catheterization.
In this case, Ogilvie fit the bill. That he smiled with his brother afterward said it all about the cath lab’s latest success.