“No one canceled myocardial infarction”: cardiac surgeon Leo Boqueria continues to operate, despite the coronavirus pandemic

- Leo Antonovich, you have come a long way in medicine. Why did you decide to become a doctor?

- Mom remained a widow at 38, there were three of us, I am the youngest. I was an excellent pupil at school, but I didn’t have an understanding of where I would go to study. My older sister graduated from medical school and really wanted me to become a doctor and certainly a surgeon. All parents in Georgia, both then and now, dream that their children should become doctors, so I decided to try it too. The first time I didn’t enter, I went to work on the construction of a tea packing factory. The next year I went to Moscow and entered the 1st Sechenov Moscow Medical Institute, with which my whole life was eventually connected. 

“Why did you choose cardiac surgery?”

- In the fourth year, I somehow met with classmate Borya Gelfand, a future academician. He was the head of the circle at the department of operative surgery and topographic anatomy and decided to move to another scientific circle. They agreed to let him go if he brings a replacement. And then he meets me and says: “Why don’t you do scientific work? So, we do experiments on dogs: we stop the heart, do trial operations, and then we start the heart again. ” Then all the experiments were done on dogs. Of course, this madly interested me, and in the end I replaced Boria in a circle. It was the department of operative surgery and topographic anatomy, which was headed by the rector of the institute, academician Kovanov Vladimir Vasilievich.

 - This was your fateful moment?

 - Yes, right after graduation, I was assigned to graduate school, where I continued my research on a new method of protecting the body when the circulation stopped - hyperbaric oxygenation. On defense of the dissertation, one of the opponents was Vladimir Ivanovich Burakovsky, who a year before had become director of the Institute of Cardiovascular Surgery named after Bakuleva. He, together with another student of Vladimir Vasilievich Kovanov - Boris Alekseevich Konstantinov - just opened a department for children under three years old with heart defects, which had no analogues at that time. Mortality from the treatment of heart defects at this age was very high. 

Burakovsky realized that the method I proposed could be a salvation for children with congenital malformations of the blue type, whose lips are purple, fingers with cyanosis. If they are operated on in the baro-operating room (special operating room with increased oxygen pressure. - RT) , under increased pressure, their oxygen will normalize, and they will be able to postpone the operation. And after the intervention, they already have everything, like normal children. After reading a dissertation, he called me himself and suggested right after graduate school to go to work at his institute. It was a great joy for me, after all, after the theoretical department, we all wanted to work as surgeons in practical medicine.

- How did you get this transition?

- In 1968, after successfully defending my dissertation, I became an employee of the institute. But then they gave me very little to operate. And I was going to leave the institute, about which I repeatedly spoke to the director. And then Burakovsky said: “Find some other new topic, I’ll open a branch for you - and operate as much as you want.” So I again “sat down” in the medical library and found a topic: life-threatening tachyarrhythmias.

This is when, for various reasons, the heart begins to contract with a frequency of 150-250 beats per minute. At that time, only two clinics in the world operated on patients with such an ailment with good effect: the so-called supraventricular tachycardia was practiced at the Duke University Medical Center in the USA, and ventricular tachycardia was practiced at the Drink-Salpetriere Clinic in Paris. Vladimir Ivanovich Burakovsky appreciated the prospects of the problem. The fact is that in addition to the high independent significance of tachycardia, they often complicate the course of heart defects. To tackle a completely new problem, it was necessary to assess the situation on the spot. Burakovsky went to the Minister of Health, the great surgeon Boris Vasilievich Petrovsky, with a request to send me on a business trip to the United States. In November 1979 I visited the Duke Center in Durham (North Carolina.  - RT ), and in June 1980  - in the hospital Pitié-Salpêtrière in Paris. Both missions took place within the framework of interstate agreements on medicine, effective until 1989. As always happens at the beginning of the journey, such operations there were mainly done back in the experiment on dogs. The clinic had literally several operations on a person.

Of course, our colleagues did not think that we would quickly master these complex electrophysiological techniques. But everything worked out, and already in 1980 the operations were “put on stream”, and in 1986, for the work on the surgical treatment of life-threatening tachyarrhythmias, we received the USSR State Prize.

For this period, the center of Bakulev already had the greatest experience in treating all types of life-threatening arrhythmias, including when combined with heart defects in adults and children, and I have the largest personal experience in the world - more than 2500 operations.

Next, we created several branches in this direction. The innovative contribution of our team to practical medicine is recognized worldwide. It is precisely the fact that life-threatening arrhythmias "accompany" any heart disease that made it possible for me to operate on the most diverse pathology of this organ.

In September 1994, the director of the institute, the great heart surgeon Vladimir Ivanovich Burakovsky passed away. Before that, he had been sick for a long time and understood that it would be better if he himself offered a replacement. He had three deputies. Burakovsky sent a letter to Yeltsin with a request to support my candidacy. He handed the letter with this request to Yevgeny Maksimovich Primakov.

“I wonder what he wrote to him specifically?”

- Primakov, who transmitted this letter through Sergey Alexandrovich Filatov to the president, showed me this letter after Yeltsin looked at it. It began like this: “Dear Boris Nikolaevich! You, as a Russian, after my death, should appoint Leo Bokeria to be the director of the Center. ” And then it was written about me. The answer of Boris Nikolaevich, according to Yevgeny Maksimovich, was this: “I don’t know Bokeria, but if Vladimir Ivanovich wants to, I don’t mind.”

Why Burakovsky stopped on my candidacy, I do not know. Perhaps because at that time I was the only full member of the Academy of Medical Sciences in the team. For me, as for everyone at the institute, untimely departure from the life of Vladimir Ivanovich Burakovsky was an invaluable loss.

Then we completed the Center on Rublevskoye Shosse and a friend of Burakovsky —  then the head of government, Academician Primakov  — personally opened the institute named after his friend ,  the Vladimir Ivanovich Burakovsky Research Institute of Cardiac Surgery, one of the two institutes of the Bakulev Center for Cardiovascular Surgery.

And we became the largest clinic in the world in terms of open heart surgery. More than five thousand open-heart surgeries are performed annually at the center. And from them more than 2,5 thousand - to children.

I hope that the process will continue. And this will be the best memory for our great teachers - Bakulev and Burakovsky.

- Now there is a very large demand for nostalgia for the 90th. Let's recall the story of how the whole country found out what coronary artery bypass grafting is. We are talking about an operation on the heart of Boris Yeltsin in November 1996. That story probably did not pass you by.

- Boris Nikolaevich’s illness coincided with the first international conference on the history of cardiovascular surgery, which was held September 25-26, 1996. I wanted to perpetuate the memory of Vladimir Ivanovich Burakovsky with the participation of the most prominent scientists, so that they made presentations. Among them was Michael DeBakey. I'm going to the airport to meet DeBakey, but he is not. It turned out that he was right at the plane's ramp met by our chief cardiologist Evgeny Ivanovich Chazov and had already taken away for some consultation. But Dr. Debeiki knew well, because he was operating at the institute on Leninsky Prospekt at Mstislav Vsevolodovich Keldysh, president of the USSR Academy of Sciences.

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“Have you already met him?”

- Yes. Then seven outstanding cardiac surgeons from the USA alone came to the conference, among them Michael DeBakey. Among the guests, for example, was Walton Lillechai, who, along with John Kirklin, is still considered the founding father of cardiovascular surgery. In the evening of the same day, the widow of Burakovsky gathered guests at home. DeBakey then said, commenting on the consultation: “If I hadn’t been told that he was a sick person, when I saw Yeltsin, I would never have thought about that.”

But the president’s coronarography, he said, was very poor, it was necessary to operate.

- Is it known how the surgeon was chosen?

- I heard that three candidates were discussed. They were interested in my opinion, and I said that it is better to call a foreign specialist, so that later, in case of an adverse outcome, they will not curse the doctor who will operate.

But in the end, they trusted Renat Suleymanovich Akchurin to operate. Everything went well, and Boris Nikolayevich continued to work for several more years. Three years after the operation, he handed me the order, and, as I recall, he looked good.

- What was the role of Debeika in the end?

- During the operation, according to him, he was in the next room and watched everything on the monitor. As they say, just in case.

- You operate on children. Often those who are several days old. How have we solved the issue of pediatric transplantation? This is often the only chance of salvation.

- Our children are considered to be 18 years old. In my opinion, there was a case when an adult heart was transplanted to a 12- or 13-year-old child. This is not specifically indicated in the specialized literature. 

The problem is that in 1992, when the rules for stating brain death were prescribed, among the compilers, as far as I know, there were no cardiac surgeons.

In transplantology, no matter what is said, the main thing is a heart transplant, because all other organs are more tolerant of lack of oxygen. And for many years we did not manage to do anything in this regard. Despite the fact that there was even a period when I transplanted an artificial ventricle of the heart to the boy under the guarantee that in 3-4 months we would be able to have him transplant the whole heart. And the minister said then that they were about to be allowed to do a child transplant. As a result, they were not allowed, and this child had to have a heart transplant in another country. For this, a special aircraft with all that was needed was allocated. Fortunately, nothing happened.

- That is, only one chance - an operation abroad?

- Now abroad, a complete ban on heart transplants to foreign citizens. Because their citizens everywhere lack donor agencies, including the USA, Germany, Spain, Italy and others. Society must agree with this. But now in our country there is permission for such operations.

The boy, who was operated on in Italy, was transplanted the heart of a child who had a severe accident while in the car with his parents. There was no chance of saving the child, but the heart was functioning well. And when the Italian mother was told that there is a child who really needs her baby’s heart, and that her child will continue life in this way, she agreed to take the heart of her child. And that boy - our compatriot, with a transplanted heart lives here, in Russia, grows.

“But besides the moral and ethical aspect, there is a danger of criminalization.” Perhaps they are still afraid of this, especially with regard to children?

- No. Such operations can be done in Russia in a very small number of centers. Everything is so transparent there, so many people participate in the process that there is no way to do without information leakage. I have come across this many times. And the questions immediately went away. They bring a person. First, at the reception, they examine and make a diagnosis. Everything is documented. There are clear signs of brain death incompatible with life. Then the council is going to make a decision. Then it is agreed with relatives. If relatives cannot be found, this is agreed with the supervisory authorities.

After this, a protocol is drawn up and organs are removed: heart, liver, kidneys, lungs. That is, at the same time 3-4 people come to life, or even five. Organ harvesting can only be done in specific hospitals, where there is full equipment, where the appropriate staff works. So the stories about “black transplantologists” are all fictitious.

This is just to slow down the development of our medicine.

- You work, despite the coronavirus raging in Moscow. You can’t isolate yourself, as they should operate?

- Of course. In our country, cardiovascular diseases carry 56.4% of the total number of deaths annually. These are hundreds of thousands of people.

No one canceled myocardial infarction, acute attacks in newborns that require emergency surgery.

There are urgent planned operations in patients with two to three affected valves.

- By the way, after leaving the post of director of the Bakulev Center at the end of last year, you became its president. What are your responsibilities?

- First, and most importantly, I continue to do several operations a day. As I left at 07.45 in the operating room, I am leaving. Today, the flow of patients has sharply decreased, so now I have about two operations a day. Many years ago, I created a department that does 850 operations a year on a stopped heart. This is more than any other federal clinic in Moscow.

I had more opportunities to do rounds in the department, to do graduate students, residents. And from the point of view of real administrative functions, of course, the president does not have them in fact. The question of my resignation was then decided by the age principle.

- You yourself had no desire to leave the post?

- Did not have. It was also realized somehow unethical. I am talking about this for the first time. Five days before the end of the contract, my signature was closed at the bank. Nobody knew about this at the institute, not even bookkeeping. It is as if I could spend 2.5 billion rubles that were on the account of the center over these three or four days. And two days before the deadline, at that moment I was in the operating room, a “red” telegram came from the Ministry of Health that the contract with me was not renewed. I come from the operating room, the secretaries have eyes in a wet place. I went into the office, and on the table lies this telegram.

Then everything was very simple. The minister arrived (Veronika Skvortsova. - RT ), we went with her to the hall where a new candidacy was announced.

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• © Kirill Kallinikov

- You are also engaged in social activities.

- In 2003, Yuri Leonidovich Shevchenko, a well-known heart surgeon, called me, he was then the Minister of Health. I’ll also reveal such a family secret: he is the godfather of my twin grandchildren. So he called and said: “We are creating a new public organization - the League of Health of the nation. You can’t get away: you must be the president. ” I tried to resist, but to no avail.

And I am such a person: if I took up something, I am ashamed not to do it, I consider it below my dignity.

Today, the Nation's Health League is a serious platform for discussing topical issues of national health.

- As I understand it, the main direction there is enlightenment?

- Yes. Conducting such nationwide large-scale events as the annual forums “Health of the nation - the basis of Russia's prosperity”, “10 thousand steps”, “Walking with a doctor”. I remember how I flew to Samara and was shocked: the whole promenade was filled with people who came for a "walk with a doctor." The idea is that anyone can see a doctor in a relaxed informal setting. In Moscow, we held such an action in the area of ​​Krylatsky. I came there ten times, and behind me there was a line of people who wanted to ask me their questions.

- You mentioned the action "10 thousand steps." Why exactly 10 thousand?

- Because it is reliably proven that the most effective method of healing the nation is walking. Not running, not jumping, namely walking. The Americans conducted a gigantic randomized study, where they proved that a person who walks two hours a week walks, he lives 6-7 years longer than someone who leads a sedentary lifestyle.

- Since the spread of coronavirus, one of the most discussed has been the issue of the presence or absence of ventilators. What is mechanical ventilation?

- Artificial lung ventilation assumes that you take an anesthetic tube, insert it through the mouth - mainly, or through the nose - very rarely, into the trachea, and connect it to the mechanical ventilation device. A special medicine is introduced so that the patient does not interfere with the apparatus breathing. This is done until a person has a reflex of independent breathing. The modern artificial ventilation apparatus is very sensitive: as the lungs strengthen their function, the device delivers less and less inhaled mixture.

And the moment comes when the device is turned off for two or three seconds, the patient is asked to breathe on his own and see if he can take a breath. And if all is well, then it is removed from the ventilation. 

But in order to leave a person with a doctor so that you can feed him and communicate with him, we prefer to put the receiver directly into the trachea. To open the mouth, to open the nose. And this is called a tracheostomy.

- In the end, I wanted to ask: is it true that at work you often chat and gossip with nurses?

- This is absolutely true, and I am very proud of it. Our nurses are wonderful, amazing, beautiful. They are eight, sometimes nine hours, stand at the operating table. And since I do several operations a day with different teams, I have such an opportunity: come, say, to Alla, and say: “Listen, what happened to Nina there?” She begins to respond: "What happened?" I fall silent, and they begin to share their sore. This is my big trick, I think. But I myself am definitely not a gossip.