Triplets have back-to-back heart surgeries at The Iowa Clinic.
by The Iowa Clinic on Thursday, July 23, 2015
Your Local Health | Written by BJ Towe
Just days old, the Steinberg triplets had back-to-back heart surgeries – all performed by Christopher Komanapalli, M.D., and Brian Rundall, D.O., Cardiothoracic Surgeons with The Iowa Clinic. Imagine repairing a blood vessel in a premature infant's heart that is about the size of the letter “e” at the end of this sentence. Then imagine doing it three times in a single day – on triplets who arrived four months early. That's exactly what Drs. Komanapalli and Rundall did.
The Back Story
Jim and Dani Steinberg of Adel headed to the delivery room on July 13, 2014 – 16 weeks before their triplet daughters would have reached full-term. “We were terrified, to say the least,” Jim says. “It's not the normal way of going into delivery. As it was happening, you kind of expected the worst.”
Perry Osborn, D.O., an Obstetrician with The Iowa Clinic, delivered the less-than-two-pound Steinberg triplets – Tinley, Giuliana, and Jasmine – by caesarian section. “One was born without a heartbeat,” says Dani. But neonatologists, who were in the delivery room to provide immediate care to the babies, quickly got her heart beating again.
Not developmentally ready to enter the world, the triplets needed the specialized care and technology provided in Blank Children's Hospital Neonatal Intensive Care Unit (NICU). Each baby was assigned her own neonatologist (who specializes in caring for critically ill newborns) and an extensive team of nurses, physicians' assistants, respiratory therapists, and other practitioners and technicians.
“Two of the girls had intestinal perforations requiring emergency surgeries on days five and six. They had very underdeveloped lungs, so everyone was having trouble breathing,” says Dani. All three of the girls were on ventilators for weeks.
The Triplets Need Heart Surgery
A few days later, the Steinbergs learned their daughters all had PDAs (Patent Ductus Arteriosus). PDA occurs when a blood vessel that connects two major heart arteries doesn't naturally close as it should after birth. Left open, a PDA can damage other organs in the body.
“They were so tiny when born, PDA was one of the things discussed as being a potential issue. But there were so many big issues going on, it was not our primary concern,” says Dani. Around the triplets' 10th day, their blood pressures became low: “That was the PDA,” Dani says. Surgery was imperative to prevent long-term repercussions.
Komanapalli was scheduled to see patients in his office that day. But when the neonatologists called about the Steinberg triplets, he and Rundall quickly responded.
Back-to-Back Surgery Performed in Less than 5 Hours
Drs. Komanapalli and Rundall specialize in adult cardiac surgery, but they are also qualified to perform some procedures – including PDA ligations – on infants. “We do these ligations frequently and have had good results. But never have we done three all in the same day,” Komanapalli says.
Komanapalli explains the procedure: “The vessel that needs to be closed is about half the size of a pencil lead. You have to separate it from the surrounding structures and put a clip on it. That solves the problem. It's not a complicated procedure, but you're dealing in a really small space on a really tiny baby.”
The surgeries would be performed in the girls' room in the NICU. That required creating a sterile environment around each crib. “Each surgery took about 20 minutes – the set up and tear down took longer than the surgeries. The entire process took about five hours from start to finish,” Jim says.
The procedures were performed in order of how sick the babies were, with the sickest one being first.
“The first two had underdeveloped lungs and were actively ventilated while we were operating in the chest. This made the operation more challenging because the lungs had to be moved out of the way,” Komanapalli says.
Dani says the day was a whirlwind, but she remembers being struck by the number of medical personnel involved in her babies' care. “I wrote them down: There were two surgeons, three NICU nurses, a neonatologist, a nurse practitioner, a respiratory therapist, and a different anesthesiologist for each baby. There were also three to five surgery nurses and technicians in and out of that room throughout the day,” she says.
Despite the bustle and buzz, the staff kept the Steinbergs top of mind and well-informed. “They did a great job updating us and checking to make sure we were holding up okay,” Dani says.
The surgeries went like clockwork.
“It was amazing how quickly their blood pressures really popped up, which helped support everything else,” Dani says. “Their respiratory needs were less. Their hearts were able to more efficiently pump blood through and get oxygen to their bodies.”
It Took a Village
The girls all got to go home between five and six months after their births. “We got our first one home in time for Christmas, which was exciting,” says Dani.
Today the triplets are all doing well – and keeping their parents very, very busy. “They're gorgeous; you'd never have any idea (of what they've been through). One is crawling, two are rolling, and they talk like crazy. They are sweet, happy, and a bundle of fun,” she says.
Recalling those days at Blank, Jim says, “We had an amazing team. We were in good hands.”
Komanapalli emphasizes, “It's important for people to know that great medical care doesn't happen with just a doctor working as an island. It's all of the neonatologists, surgeons, respiratory therapists, physician's assistants, nurses, and technicians – they're all really dedicated people who take great care of our patients. It is said that it takes a village to raise a child. We have our special village, and that allows us to do some pretty amazing things.”
How Humor, Confidence and Compassion Helped
In addition to having highly specialized care, the Steinbergs say having caregivers who put them at ease was invaluable. They're quick to praise all of the people involved in their daughters' care.
“And Dr. Komanapalli … he's not at all what we expected. You expect your doctor to be intelligent and confident, but you don't expect such a big heart. He made us smile. He really wears his heart on his sleeve,” says Dani.
“You don't always get that from a doc,” Jim adds.
To that, Komanapalli responds, “When you're dealing with a serious medical condition, people are scared. It doesn't help anyone if you come across stuffy. People are more receptive to what you're trying to say if you have a sense of humor, are confident and just a nice person. It helps everyone involved, and – as a physician – that's what I'm trying to do.”
Patent Ductus Arteriosus (PDA) is a relatively common heart problem affecting newborns, especially premature babies. It causes blood to flow abnormally between two of the major arteries connected to the heart – the aorta and the pulmonary artery.
Before birth, the aorta and pulmonary artery are connected by a blood vessel (the ductus arteriosus), which is necessary for blood circulation in the womb. Usually, the vessel naturally closes within minutes or days after birth. When it remains open (patent), oxygen-rich blood from the aorta mixes with oxygen-poor blood from the pulmonary artery, which stresses the heart and increases the baby's blood pressure.
PDA increases the flow of blood through the lungs, which reduces blood flow to the rest of the body and can damage the intestines, kidneys, and other organs. PDA ligation is a surgical procedure that closes the vessel, which allows blood to flow normally.