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Guillermo Young, MD Transcript 114

Nov 24, 2017

Dr. Young graduated from the Univ Nac Mayor De San Marcos, Fac De Med, Lima, Peru in 1967. With more than 50 years experience, Dr. Young is the oldest pediatric cardiologist practicing in Los Angeles. He is affiliated with Ronald Reagan UCLA Medical Center. Dr. Young discusses the history of the cardiac catheterization.

I'm Dr. Guillermo Young. I'm a pediatric cardiologist, originally from South America, Lima, Peru, but I came here to the United States when I was about 27 years of age. Most of my life has been here in Los Angeles.

I've been practicing pediatric cardiology since 1974, which is about 43 years already. I'm 77 years old, and I'm the oldest pediatric cardiologist practicing in Los Angeles. I'm not planning to retire yet. I have a lot of patient, I'm in private practice, but I'm associated to UCLA because I train and finished my training at the UCLA in 1974. Because I have so much experience in the pediatric cardiology area, I can say that I really have seen almost everything. But being medicine, you cannot say that you have seen everything because there is always something new coming about, and you have always learning.

In fact, many years ago I introduced a group of physicians from many countries, and I said to the group, I was introducing them as students, because I didn't know if they were medical students or physicians already. Then when I was corrected, they were physicians already, I said to them, "Well, I'm not going to apologize because I've been doing pediatric cardiology and being a doctor for so many years, but I'm still a student." Oh, everybody applauded me like you have no idea, it was incredible. That's the truth. A doctor never finishes studying. That is a good doctor.

In regard to what I do, I do clinical work in pediatric cardiology, but I do invasive procedures as well, and intervention with the assistant of one of my colleagues, Dr. Levy, that is a wonderful pediatric cardiologist, now. He is one of the assistants of Dr. Alejos at UCLA in the catheterization lab. He has taught me many things because he has developed his own technique.

Well, in regard to the cardiac catheterization, I've been doing cardiac catheterization ever since I start my fellowship which was in Detroit. During that time, we didn't even have the ultrasound. The echocardiogram happened in the '70s, and I started in '69 doing my training at Children Hospital. We were just using our stethoscopes, our hands, ears and that’s - just to make diagnosis. We used to have the electrocardiogram and the vector cardiogram that now has almost disappeared. But then that is one of the reasons why we have to catheterize almost every single patient that had a murmur. So, at Children Hospital Michigan, I remember we used to catheterize three patients a day, every single day.

Then when I moved to UCLA, one of the professor there, Dr. Isabelle Jones, she taught me how to do the percutaneous. Okay, so we didn't have to do cut downs. Before that, we used to cut the groin and then put in needles and wires and catheters into the heart. But with the cut down. That's what we used to do. Cut down about half an inch of the skin. But when Dr. Jones told me that the percutaneous was very simple, it wasn't at the beginning.  So I start doing that. A procedure then you just anesthetize the patient wholly with an anesthesiologist, and then a local anesthesia in the groin. Then you just feel, palpate, the arterial in the area of the groin and then, once you localize the artery, then you just know then by going with a needle you're going to hit the artery. And then a few millimeters inside you going to have the vein. Then we developed the technique, which is the only one we use nowadays. I haven't done a cut down, I think, in about 40-something years. That's what Dr. Alejos does.

I used to catheterize almost every patient before the era of the ultrasound echocardiography. Then in the '80s, it came ultrasound. It came what we call the M mode which was just pictures like you landed in the moon. People couldn't understand how could we make diagnosis with those pictures. But we recognized the pattern of those M modes and then we just made the diagnosis. But then, late in the '80s, it came the two-dimensional ultrasound echocardiography. That was the most wonderful, I would say, assistant that we have had to add to the diagnosis. It has been very accurate. Things that we couldn't recognize but we have to catheterize the patient, with the ultrasound we don't need to.

But why do we catheterize patients then if we recognize with the echocardiogram? In fact, it is true. We do not send patients to surgery as before with a cardiac catheterization because now with the echocardiogram the surgeons, they are familiar with the system, and then they just accept the diagnosis and they proceed without the cardiac cath. But so why do we still have a cardiac catheterization? Now, one, it's not diagnostic anymore, because we know already, but it's mostly to do procedures or to emphasize the progress of process. For example, pulmonary hypertension. That is very important because with pulmonary hypertension, we have to know not just the anatomy because we know it, the EKG tell us, the echocardiogram tell us, but the echocardiogram is going to tell us what are the hemodynamic changes of the pulmonary vascular resistance, which is what the pulmonary vascular bed ... Because remember the vessels, the capillaries in the lungs are so tiny, tiny little vessels that they have muscle. They have what we call a medial, a medial that is full of muscle.

In pulmonary hypertension, that medial is very, very reactive. Normally, every baby is born with pulmonary hypertension. Every baby is born with the pressures equals in the right side of the heart than the left side of the heart. But in the first 24 hours, the pressure drops, and by 48 hours, it should drop 40% or 50%. And then continues to drop as the baby gets older. By 12 weeks, the pulmonary vascular resistance is perfectly normal in the baby. Some babies, when they have what we call familial pulmonary hypertension, they don't do that. They remain with a thick medial. Doesn't give up. So, the medial continues to hypertrophy, means that it's lifting weight like an athlete that is lifting weight and his muscle in the arms gets very thick. The same thing happens to those kids when they are born that way.

That is if the patient has pulmonary hypertension of the familial type of the so called idiopathic type, but in the old times, we used to have more pulmonary hypertension that is related to the congenital heart defect, like a patient I just lost last week. 52 years of age. But the most common pulmonary hypertension in the old time was when you had a huge hole in the lower chambers or a big tube connecting the two main arteries. That generates a very high pressure going into the right side of the heart, which is going into the lungs. The lungs react. Because that reactivity, they have to protect the patient from congestive heart failure by constricting the pulmonary vascular bed, so limiting the amount of flow into the lungs so the patient doesn't go into congestive failure.

But by doing that, that media hypertrophy of the tissue in the lungs stay there. In fact, getting fibrosis. Scar. When you develop a scar, it's not like muscle. Muscles relax and respond to certain medication or to oxygen or to certain gases. That when we need to go into the cardiac catheterization to see the reactivity of the pulmonary vascular bed of the patient. So, we have certain parameters to see if the patient’s pulmonary vasculature is reactive or is not reactive. If it is, how much is going to respond to the medication that we're going to give to the patient.

This is something that we didn't know until just few years ago. A patient, for example, with primary pulmonary hypertension, the familial type, and it happened to me, I lost two brothers about 18 years ago with primary pulmonary hypertension. I'm following now the youngest brother that he didn't get it. He doesn't have anything. But the first one died at two-and-a-half years of age, we didn't have those medications. And the other one died when he was about 15.

The only thing we offered to him at that time was a lung transplant. But the technology of the lung transplant 15, 20 years ago was not as successful as it is now. So, the kid was very bright, so this was at Children Hospital of Los Angeles, so when the surgeons there they told him that he has to have a transplant and usually it wasn't going to last more than three years. What I did at that time is I opened up a hole in the upper chambers on him. To decompress the right articular pressures. So he traded a pink situation with a blue one. So, he turned a little bit blue. His liver was not enlarged anymore, his legs were not swollen. He did very well for about two years.

Then, when they were going to do the lung transplant he was very smart, very conscientious kid, and very hard worker. He knew he was going to die. This is something very important to learn. He knew he was going to die. He accepted it. But instead of sitting down in a wheelchair as he used to be confined to, he learned to knit things with plastics thing and he start developing thing like key holders, bookmarks. And he will go to one of those shopping malls and start selling his product. It was amazing. He was getting some money out of it, to the point that before he died he told his mom, "Mom, when I die, don't throw anything than any box from my bedroom. Just take a look at what is in each one of those boxes." That's what he told his mom.

The last time I saw him, this is many years ago, it was close to Christmas, and he knew that I loved chocolate. So, the year that he came before he was going to die… he died on Christmas Eve, it was about 24th, but day before he came and he gave to me a huge bar of chocolate. About five inches high. It was a huge. I said, "Come on. Why did ... ?" "Well, Dr. Young, I don't know if next year I'm going to see you so this is just for you to enjoy it." Okay, he was so good, I never seen a human being so happy, so wonderful. And loving. In fact, when he died and the mother called me, oh, it broke my heart because it was New Year's Eve. But the mother accepted because she lost a two-and-a-half year old about five years before and then this one. But we knew what was going to happen. But he really died with dignity and not being afraid of anything. It was a lesson that I learned from him.

Let's go back 15 years ago, 20 years ago. The prognosis and the future of these people was really poor, very bad. Think about 20 years ago. We didn't have anything to offer to the poor parents because you have to learn one thing. In our specialty, the patient doesn't suffer as much as the parent. That's what I learned. The patient, once he knows his diagnose, he doesn't even know what it is. He keeps running and playing and jumping and doing whatever he does. But the one that struggle and suffer is the family, particularly the mother. It is amazing what the mother, the fear of a mother to lose a child is something that we, males, do not understand because we don't have that gene of being a mother that they do have.

But then, look at now. We have patients then they are living much, much longer. And this is just what? 10 to 15 years. Okay, but now, what is going to happen in about 10 to 15 more years? In the old times, a lot of our patients born with congenital heart defect we gave reassurance to the parents that the child is not going to make it. So that was our function. Now, almost all of them, they go into surgery. They're going to have three procedures, but in six years they are going to be "cured" and doing normal activity as a normal child.

So, what is going to happen in 10 to 15 years with all this product that the companies are developing and the doctors are experimenting in these patients that probably the survival is going to be forever. I don't know. I've been so thankful to live this long and practice this long to see how much we have really improved in our field.

My name is Guillermo Young, and I am aware that I'm rare.

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