The Guardian Angel of Children’s Medical Center

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heartmdBy Brantley Hargorve

DALLAS (D Magazine) — A light rain falls outside of Children’s Medical Center at 7:30 in the morning as Dr. Kris Guleserian makes her rounds. All down the L-shaped corridor can be heard the even tone of heart monitors and the hiss and click of respirators. Guleserian absorbs the night shift’s report, issues instructions, and heads for her office on the third floor, the sharp report of her heels receding down the long hallways.

She sheds her flower-print Roberto Cavalli dress and Christian Louboutin heels, and pulls on blue cotton scrubs and a pair of Dansko clogs. The tight curls of her dark, shoulder-length hair bunch into a disposable cap. She threads through a locker room, a series of heavy wooden doors, and enters the operating-room suite. At a sink outside of the operating room, she scrubs her hands and forearms with chlorhexidine soap, then steps into the OR.

At the center of the room is a 6-by-6-inch square of flesh, the rising and falling chest of a 9-month-old girl slathered with ochre iodine. The rest of the child is hidden beneath tented folds of sterile blue sheets. Guleserian’s assistant helps her into a surgical gown and a pair of Biogel gloves pulled high over the sleeves. The 5-foot-nothing woman—the only female congenital cardiothoracic surgeon UT Southwestern has ever had, and one of only 11 board-certified in the entire country—mounts a stool next to the table. With a black marker, she traces a straight line down the lower half of the little girl’s sternum.

Today, Guleserian will open her chest and repair a rare congenital defect known as Tetralogy of Fallot. In the womb, when the child’s heart began to fold and divide from a simple tube into four pumping chambers, something went wrong. The misaligned muscles failed to fully connect. A hole—a septal defect—formed in the wall separating the main chambers, and the errant tissue obstructed the pulmonary artery, which carries depleted blood to the lungs for oxygenation. As the heart struggled to compensate for these malformations, the right chamber thickened with the effort. When the blood leaves her heart, it should be a rich, healthy red. Instead, her exhausted blue blood mixes with and diminishes the vital stuff. She’s usually tired, weak, her lips and extremities often an oxygen-starved pale blue. Without this surgery, it is unlikely she will survive for long.

Guleserian can fix her.

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In a voice betraying a hint of her native Boston, she asks for the scalpel. The blade slips over and through the delicate skin, fine beads of blood forming on either side of a 4.5-centimeter incision. Then, the electrocautery knife cuts and burns through layers of subcutaneous fat and fibrous fascia, on down to the sternal bone. Thin curls of smoke waft toward the bright lights. Accompanied by the brief whine of a saw, Guleserian spreads the girl’s chest cavity. Her heart, not much bigger than a walnut and the color of pork tenderloin, clenches and swells, exposed to the world now. Guleserian’s large, expressive green eyes peer through magnifying loupes into the child’s chest. She knows this heart — it might as well be her brother’s. In a few minutes, it will cease beating by design. She must work quickly.

Guleserian knew early on that something was wrong with her brother Michael’s heart, in that essential, simple way children know things. He became winded on short walks to the store for ice cream and had to be carried the rest of the way by their mother. When they darted through the halls and staff-only innards of Boston’s Sheraton Commander Hotel, which their father’s family owned, his lips and fingers would turn an alarming shade of cadaverous blue. At dinner, he would announce, “Mommy, I’m tired,” and promptly pitch forward into his food. Michael couldn’t have known why he did this, but sometimes, when he felt an episode coming on, he would settle into a low squat to force more blood through his heart. The boy had barely learned to speak, yet he could succinctly convey what was wrong with his body. One day, he was on his knees, pointing to his chest. “Sick, sick, sick,” he repeated. His odds of making it past three years were slim unless he underwent surgery soon.

By 2 years old, they couldn’t afford to wait any longer, and his doctor hoped he was strong enough to withstand the trauma of an open-heart procedure. When the day arrived and it was time to depart for the hospital, Guleserian’s mother suggested that she stay with her grandmother, but the child — now 4 years old and a big girl — insisted on coming with them to Boston Children’s. The surgeons were going to perform a stopgap that could save Michael’s life: halving and repurposing a major artery in his right arm, which they would tie in to his heart to shunt blood from the obstructed valve and muscle beneath to his lungs. The mortality rate for the procedure was 50 percent, but all she knew was that the man in the white coat was going to fix her brother. When he woke with his parents and sister at his side, the wound traveled in a livid, sutured line from his sternal notch on down to the bottom of his sternum. He was in the hospital for a month.

But once he recovered, the boy flourished as he never had. Color bloomed in his cheeks. He could run and play and roughhouse with his tomboy big sister. At 6, hale and growing, he underwent a second operation—the full repair of his heart. While his sister went out for field hockey, soccer, and lacrosse, the kid who once face-planted into his dinner made the football team. For Guleserian, the tet spells and the blanching skin faded into memory, at least for a time.

There was a neighbor boy named Tommy Kaplan, 8 years old to her 9, who looked the way Michael used to, only worse. He was small, underdeveloped, his skin an ischemic blue. His older brothers helped him board the school bus every morning. Though they had recess together, she never asked Tommy why the doctors couldn’t make him better the way they had Michael. She didn’t understand that he didn’t need a Tetralogy of Fallot procedure like her brother — he needed a new heart and new lungs. But the first pediatric transplant was still seven years away.

On his ninth birthday, Tommy ate lobster, pulled on the Red Sox uniform his parents had bought him, and drilled a home run across the yard. Afterward, he told his mother he was tired and needed a nap. He went inside, crawled into bed, and never woke up. When her parents told Guleserian about Tommy, it got her thinking. She had learned early on about the ways in which the body could betray. Her brother’s heart had been sick.

“Is my brother going to die, too?” she wondered. “When is Michael going to die?”

Before long it became clear that Michael didn’t need Guleserian to look out for him anymore. He didn’t die, of course, and the spells never returned. In fact, he scarcely remembered the blue skin and the surgeries that she can never forget. He went to a school for boys, and she to a school for girls.

Guleserian had always been a restless, ambitious child — determined to excel academically, her extracurricular activities a dizzying series of games and practices and lessons. She thrived on a feverish pace. And in the feminine cloister of Boston’s Winsor School, she was insulated from the patriarchal world and the insinuated limitations beyond its doors. The editor of the school paper was a woman. The class president, too. Nearly all positions of authority in her daily orbit were held by women. Why should the rest of the world be any different? Even in concept, if not in practice, she knew nothing of glass ceilings.

She attended Harvard and studied classics, graduating cum laude in 1990. But she had no intention of becoming an academic, even if she had a naturalist’s fascination with bios and logos, the study of life. She promptly entered Boston University School of Medicine. After that, she put in five years as a general surgery resident at Brown University and Rhode Island Hospital. The work was dull, removing appendices, re-sectioning colons. She eventually transitioned to trauma. By now, she understood the drive she hadn’t been able to articulate yet had resided within her ever since that day in the waiting room, watching the door for her brother’s doctor. She wanted to fix the hearts that had been born damaged, like Michael’s. She chose one of medicine’s longest paths and, for women, the least trod; there was no female precedent for Guleserian, no forerunner. The world of cardiothoracic surgery—and especially congenital heart surgery — was overwhelmingly, exclusively male. Yet it never occurred to the young woman from the all-girls Winsor School not to press forward, to crack the boy’s club.

In 2000, she was awarded a Harvard research fellowship at Boston Children’s Hospital, where she planned to study cardiovascular tissue engineering. On the day she went to meet with the family that had generously endowed the fund, her parents accompanied her; the Guleserians knew something Harvard did not. The two families hadn’t seen each other in decades. When Tommy Kaplan’s parents saw Kris, the girl from the neighborhood and the recipient of Tommy’s fellowship, they wept.

The research grant had never been awarded to a woman before. As the chief of cardiology at Boston Children’s formally recited Guleserian’s brief biography for the Kaplans, he remarked how “unusual” it was for a woman to train in this subspecialty. Given the male’s superior three-dimensional reasoning faculties, he opined, she was something of an anomaly. Guleserian was stunned but didn’t let it show. She was set to discuss the subject of her research at a luncheon in front of the Kaplans and a gathering of hospital muckety-mucks. As she stepped before the group gathered in the hospital’s library, she announced, “For the next hour I’ll be talking about three-dimensional imaging of the right-ventricular outflow tract in cardiovascular tissue engineering.” She hoped the good doctor was listening carefully.

Two years later, her cardiothoracic surgery residency began in earnest, and she spent two years at Washington University in St. Louis before returning to Children’s Hospital in Boston for a year-and-a-half fellowship in congenital heart surgery. This was followed by a two-month registry fellowship in Boston. By the spring of 2005, her postdoctoral training had consumed a decade of her life. She liked to joke that she didn’t get a real job until age 37.

That year, she finally took a position in Dallas as an instructor at Children’s Medical Center and UT Southwestern and was quickly promoted to assistant professor and then associate professor in 2012. She developed a reputation as the last chance for the kids who didn’t have a prayer. Guleserian took the high-risk cases, like the 3-year-old girl who needed a combined heart and liver transplant, the youngest ever to undergo the procedure. She installed a pacemaker in a premature 32-week-old baby. In 2007—when she became surgical director of pediatric heart transplantation—she performed a heart transplant on the youngest and smallest infant ever attempted (seven days old, a little over 5 pounds).

Despite Guleserian’s being one of but a few female practicing congenital heart surgeons in the country, the rest of the world seemed to be stuck in the 20th century. Occasionally, she’d enter a patient’s room and someone would hand her a food tray, assuming she was a nurse. At other times, a harried mother or father would flag her down and ask for the doctor. At cardiothoracic conferences, fellow male surgeons often concluded — absent evidence — that she was in medical device sales. She began to feel as though she had to work twice as hard, and be twice as good, to call herself a peer. She had to be tough, sharp, an alpha — and soothingly feminine all at once. But never “too intense,” she says. “Who would ever say that about a guy?”

The typical congenital heart surgeon was a tall, take-charge alpha male, with a deep, sonorous voice, not, as Gulesarian puts it, “a 5-foot woman in Louis Vuitton heels.” But she had become a favorite with the staff and patients. She knew the details of their lives the way she knew the bellhops and switchboard operators at her grandfather’s hotel. “The other guys,” says Dr. Anita Krueger, a resident learning under her wing, “I don’t think they even know I have kids.”

And she was unfailingly honest with residents like Krueger about what it took to become Dr. Guleserian. These walls and these children were her life. Her two Miniature Schnauzers had their own nanny because she could never be sure when the day would end, or begin. Plans were subject to the almost exclusively tragic materialization of donor organs for children.

“She was frank about that when I met her,” Krueger says. “She said, ‘Listen, I have the most amazing job in the world, but I’m single, 40, and it’s probably going to stay that way.’”

Guleserian had given herself over, body and soul, to this calling — and that was something she could not and would not change. She was the best, and, what’s more, she drew from an experience few of her peers possessed. The children weren’t abstractions to her. She knew what it was to be scared for someone, and to lose them. Three years ago, her father succumbed to heart failure. Many years before that, she watched her brother turn blue and slip from consciousness. And when she sat down with the parents of the little girl whose chest she was about to open, they knew she understood. Their daughter’s heart might as well have been Michael’s. There were times when she wished she could go back and fix her brother’s heart because, when her work is finished, their child won’t need a second, then a third operation—just one.

Burrowing past strata of bone and tissue is a tangle of tubes through which her life floods in rhythmic spurts into the cardiopulmonary bypass machine. Black silk sutures keep the flesh open and immobile. The chest cavity is filled with chilled saline. Her heart is still, deflated, emptied of blood. On a nearby table, an oval of her pericardium—the membrane surrounding her heart—soaks in glutaraldehyde, a chemical that will toughen the tissue for its repurposing as a patch.

Guleserian trims a swatch of Dacron fabric and closes the ventricular septal defect the child was born with. Then she slices through layers of the right ventricle and begins to carve away at the overabundance of muscle tissue. Like a tailor letting out a suit jacket, she uses the pericardium patch to augment the constricted right ventricular outflow tract. All the while, she banters about the Red Sox and the middle-aged billionaire real-estate titan who divorced his wife for a Harvard coed. There are 12 other OR team members in the room, including anesthesiologists, perfusionists, scrub techs, respiratory techs, and circulating nurses—most of them women—but Guleserian is the conductor at the center of this symphony of suctioning and forceps and the quiet hissing of bypass tubes.

The girl has been under for three hours now, and Guleserian has begun to revive the stilled heart. She removes the battery of bypass tubes and unclamps the aorta. Warm blood sluices into the heart, and for the first time in hours it begins to beat. The perfusionist eases the blood in slowly as Guleserian elevates the temperature. “She’s getting it together,” she says. Now the child is entirely disconnected from the cardiopulmonary bypass. The pale lobes of her lungs appear from behind the ribs and inflate. A cardiologist enters the OR to perform an echocardiogram, which will ensure that all holes have been sewn shut and that the valves are functioning properly. Her heart rate goes up, then down, and stabilizes.

At four hours, it’s time to close her up. Guleserian weaves the surgical steel wires around her sternum, then another layer across the fascia, and lastly over the skin. The surgeon exits the OR and strides into the waiting room, only now she’s the one offering reassuring words. The little girl’s young parents and her grandmother regard her with wide eyes. The mother’s shoulders are hunched, and as Guleserian begins to speak they visibly slacken, as though a weight has fallen away. She asks the mother if she has any questions, but she just repeats, “Thank you, thank you.”

Within hours, her daughter will be off of the respirator. In one or two days she’ll be out of the ICU. In little more than a week she’ll go home. She’ll grow up healthy and strong, with no memory of her tet spells or blue lips. Unlike Michael’s, her incision is roughly 2 inches in length. Maybe one day she’ll ask her mother about the faint line on her chest and how it got there.