King of Hearts

Over the course of the last 40 years, technological advances in healthcare have meant fewer patients undergoing radical surgeries with high risks and long recoveries. Few of those innovations have touched as many lives as the extraordinary and innovative work of Dr. Terry King.

article by Michael DeVault |  photography by Brad Arender

On the morning of April 8, 1975, Suzette Creppel was going through the final motions of surgical prep. For the first seventeen years of her life, Creppel had lived with an atrial-septal defect, a potentially lethal condition in which an individual is born with a hole between the chambers of their heart.

Since a young age, Creppel had known surgery was in her future, though she was fearful of what that would look like. In 1975, repairing an atrial-septal defect required a wildly invasive surgery in which cardiologists opened the sternum, placed the patient on a heart-lung bypass machine, stopped the patient’s heart, and then opened the heart to sew closed the defect. Even in the best cases, the procedure resulted in a months-long recovery process and a gnarly scar from just below the clavicle to below the sternum, one that patients bore for the rest of their lives. In the worst case, patients could die from the procedure or from any of a host of post-surgical complications. Sitting in the cold, bright facility, Creppel remembers her emotions well.

“I was nervous, terrified,” Creppel tells BayouLife. Perhaps it’s a natural part of the human condition. It is the only emotion appropriate when faced with an unknown, in which one of the possible outcomes is uniquely terminal. Yet, she mustered her courage and forged ahead.

With a final signature on a consent form, Creppel and her parents consigned the situation to fate, though in this particular instance, the tools of fate were two physicians at Ochsner Medical Center in New Orleans. Crowded around a single operating table in the hospital’s heart catheter lab, nurses, technicians and a myriad of other assistants busied themselves with the order of the day – a first-ever attempt at medical history. After all, just a couple of years before, the younger of the two men had been called insane for even suggesting such a procedure could be attempted, much less completed successfully. And now, at just 38, he would deploy a never-tested device in a human patient. The stakes were astronomically high.

Underscoring the importance of the moment, in a small anteroom separating the cath lab from the larger open-heart operating room, at a desk normally reserved for post-operation charting, a secretary sat cradling a phone to her ear. At the other end, the entire board of directors of Ochsner Medical were assembled, waiting breathlessly for word. With the last of the papers signed and the initial anesthesia taking affect, Creppel was wheeled into the cath lab.

The events that unfolded over the next hour in that icy room were the culmination of a path that began far from the city, removed from board rooms and air conditioning, on the black mud flats of south Texas. South Texas of the 1930s was home to two enterprises, and if you lived in the region, chances were you worked for or supported one or both of them. Cattle was king in the area, and in the vast, open skies of the ranch that dotted the countryside outside of Houston, the lights of the Humble Oil Refinery glowed on the horizon.

It’s hardly the place one might expect to find the future of cardiology, but in 1938, Terry King was born on just such a ranch near Highlands and Baytown. His father owned the ranch and worked at the oil refinery. Growing up on a working ranch was challenging.

“I did all the things that cowboys did,” King recalls. They roped cattle, branded them and herded them into stocks for sale and eventual slaughter. It was hard work, made harder by the ranch’s choice of breed, the popular but ornery Brahman cattle, known to cattlemen as one of the meanest of breeds. King agrees. “I swore I’d never own one if I got a chance to own something else.”

It was the tail end of the Great Depression and, for the most part, the country had weathered the economic collapse. Franklin Roosevelt was president, his New Deal had put people to work, and with the promise of a rosier future just over the horizon, America had started to dream again. King smiles any time he starts talking about his childhood on the ranch.

“Those old pictures you see of people sitting in front of tall radios? I remember that so vividly,” he said. It’s no surprise that King has returned to those roots with a thriving cattle ranch in western Ouachita Parish–a hundreds-acre large endeavor that boasts herds of cattle, supplies meats to numerous area restaurants, and employs a half-dozen full-time employees, including one of his sons. The ranch doesn’t include Brahman cattle, though.

In today’s world of hour-long morning commutes, interstate highways and NPR’s Morning Edition, Kingsland Ranch is barely more than a stone’s throw from Shreveport and even closer to Monroe. Routinely, individuals and families pile into the car and drive to Houston, Dallas, and points beyond. For those who don’t enjoy a drive, airlines fill in the gaps. But in the 1940s, before jet travel made the world a smaller place and Eisenhower’s interstates pulled the country into the city, northern Louisiana and southern Texas were worlds apart.
Nevertheless, every summer for much of his youth, King made the trip from Houston to Shreveport, where an uncle and aunt worked in the cotton industry. His uncle was an entomologist who specialized in hunting down one of the largest threats to Louisiana’s main cash crop–the boll weevil. In spite of sweltering heat and crippling humidity, King looked forward to summers checking cotton for the destructive devil.
“Texas was flat, black gumbo,” King says. “This, this was rolling hills, hardwoods and just gorgeous country.”
With that first visit, King was in love with the region and the work. He enjoyed being outside, found the study of insects fascinating, but the university he had chosen lacked a degree in the subject. Bugs, it seemed, just weren’t important to the University of Texas. At the end of his bachelor’s degree, and with little consideration for what his future might hold, he decided to work on a master’s degree.

By this time, he had married, and his wife wanted to study at a smaller school. Southwestern Texas State University in San Marcos fit the bill. For his fifth year of college, King decided to follow her there. It was a decision that would have repercussions on the rest of his life and on the history of medicine itself.
While in his fifth year of studies, a professor screened a movie about a heart surgeon. From the first moments, King was hooked and the film rekindled childhood notions of becoming a doctor. Recognizing the enthusiasm gushing forth from his young student, that professor had a bit of advice. “He said I needed to go to medical school,” King says. Doctors were in demand, and King saw the potential for a good career.

He applied and was accepted to the University of Texas Medical School at Galveston. Shortly before King arrived, his first son, Brady, was born. A family man now, with a wife and a child to support, King knew time was short. Galveston provided the answer. For well-qualified students–those with exceptional grades and a strong work ethic–the school provided an accelerated program. Instead of the normal four or five years of study, these students were placed on a fast track. King applied to the accelerated program and was accepted. Just two years and nine months later, he received his medical degree and began an internship at Galveston Medical’s hospital–at roughly the same time the King household welcomed a second son, David.

King’s enthusiasm, drive and skill drew the notice of the hospital’s chairman, Bill Daschner, who came to King with some unsolicited but greatly valued advice: leave. Recognizing the limitations of Galveston’s facility and the talent in his young intern, Daschner encouraged King to apply for programs at five of the most prestigious facilities in the nation. With Daschner’s help and encouragement, King sent applications to programs of study at the University of North Carolina, Duke, Johns Hopkins, Children’s Hospital of Philadelphia and Boston Children’s Hospital.

A rotation in the cath lab of Dr. Leonard Harris had instilled a fascination for cardiology and, under Harris’ guidance, King decided to pursue cardiology. In other words, King says, his professors chose his career for him, which in his estimation was a good move.

“When I first thought about going to medical school as a young kid, I was going to be a family practitioner. I soon learned I wasn’t smart enough to do that,” King says, a brief touch of the humility that’s colored his career. While much of the world looks at general practice as the lower end of medicine, for the doctor family practice requires a tremendous body of ever-evolving knowledge and treatments. More than just a viable career path, though, specializing provided King the opportunity to innovate.

After interviewing at UNC, Duke, Hopkins and Children’s Hospital of Philadelphia, King was offered fellowships at all four. One stood out, set apart from the others by the attentive nature and interest of Dr. Madison Spock, a renowned pediatric cardiologist. For the next two years, King would study with Spock at Duke. “Duke was a good choice,” King says.

Early on, he skipped a year of residency and entered into the two-year pediatric cardiology program. As important to his training as a heart surgeon was, King credits Spock with another, equally valuable set of skills. “He taught me how to do research,” King says. “He really opened my eyes.”

Spock’s research was at the forefront of electrophysiology, the study of the electrical impulses that drive the heart. For two years, King would study electrophysiology with Spock, practice cardiology and learn to be a great doctor–or so he thought. As King closed in on the completion of his two-year fellowship, Spock had other plans. “He told me I was such a country boy, I needed a third year,” King jokes.

The truth was somewhat more involved, though. Heart medicine was changing rapidly, in no small part to Spock’s own work. Adding vast volumes of information and technique to the practice, the needs of the modern cardiologist were changing and King was developing the skills of a world-class physician. King may have been the first three-year fellow, but today the program at Duke is four years long.

Amid the innovations of medicine of the late 1960s, the political turbulence of the era had its own effects. With the Vietnam War raging and no end in sight, the U.S. Armed Services were looking for doctors. King readily signed up and, almost immediately, returned to south Texas.

From 1970 until 1972, King was stationed at Lackland Air Force Base in San Antonio, the home of the 59th Medical Wing and, more importantly, the Air Force’s ambulatory surgery center. Known then and now as Wilford Hall, the facility provided physicians with as many patients as they could handle in virtually any specialty. Doctors not only treated hundreds of patients, they were expected to improve care through improving the processes of medicine and their bodies of knowledge. Cardiologists were no exception. The chief of cardiology at the time was Dr. Howard Johnson, a self-taught cardiologist of good reputation. Like all of the cardiologists on staff, King was expected to pull his weight.

One of the primary jobs of a cardiologist was and continues to be performing heart catherizations. Minimally invasive, heart caths are procedures in which the surgeon threads a tiny, flexible cable through a blood vessel in the neck, arm or groin. The procedure is commonly used to treat numerous heart conditions, check for blockages and diagnose conditions ranging from plaque buildup to mitral valve prolapse.

Heart catheterization represented the safest, most state-of-the-art treatment and diagnostic protocol of the day, but that didn’t mean the procedure was without risk. In a sometimes hours-long procedure, patients were placed under general anesthetic as the physician made the incision through which he would insert the catheter.

Then, over the course of how ever long the process took, the physician slowly and gently snaked the device through the patient’s blood vessels. Long before echograms made it possible to peer through the skin into the body’s soft tissues, cardiologist relied on feel and memory to guide the catheter with only occasional views of the catheter’s position made possible by a fluoroscope, essentially a full-body, rapid view X-ray.

Though the procedure was considered safe and routine by the early 1970s, complications were still commonplace, which rendered catheterization a harrowing experience for patient and doctor alike. During his two years at Wilford Hall, King performed more than 500 heart caths, a staggering number, and numerous other procedures–including open heart surgery to repair conditions inside the heart, such as atrial-septal defects.

During his time in the Air Force, one of King’s earliest thoughts kept cropping up. If doctors could “see” inside of the heart–by touch and feel–and diagnose problems within the heart using a catheter, why couldn’t they also fix holes inside the heart? He had raised this question before, as a young cardiology fellow at Duke, but to no avail.

“They said it couldn’t be done,” King said. “Some of my colleagues even suggested I might need a psychiatrist, that I’d lost my mind.”

Already a major by 1972, King was considering making the Air Force his life’s work. The work was challenging and fulfilling, he enjoyed it and a promotion to Lt. Colonel was just around the corner. But promotion came with a longer contract, and King had to make a decision. With Lt. Colonel just one day away, he decided to leave the Air Force. But leaving the Air Force would mean he had to find a new job. With a bevy of credentials, awards, and recommendations, King’s job wouldn’t be too difficult. Some might say a doctor in his position could write his own ticket. They would be right.

One of the first facilities to express an interest was Ochsner Hospital in New Orleans. Founded in 1942 by the charismatic New Orleans physician Alton Ochsner, the facility was recognized as one of the best hospitals in the country. Under the guidance of Alton Ochsner’s son, John, that reputation had grown such that, by 1972, Ochsner Hospital was one of the nation’s leading research and development hospitals. When King first visited Ochsner Hospital, he did not believe New Orleans was for him and decided against pursuing the position further. John Ochsner changed that with a phone call encouraging King to give them another chance and asking him to interview with Dr. Noel Mills, a renowned cardiologist. Not expecting to change his mind, King reluctantly accepted the second invitation.

During the interview, Mills quizzed him about his experience, and about his research background. Ochsner was, after all, a research hospital, and physician research was expected. Somewhere during the interview, King’s mind drifted back to his days at Duke, to that first notion of closing heart defects without open heart surgery. He raised the subject with Mills. If surgeons could diagnose the size of a hole in the heart with a catheter and a balloon, didn’t it stand to reason that they could also develop a tool to close that hole? Mills shoved back from the desk, astonished.

“He jumped up, ran over to a desk drawer and pulled out a bunch of catheters,” King says. He had found in Mills a kindred spirit who understood the challenges and potential techniques surgeons might use to close atrial-septal defects without cracking a sternum and stopping a patient’s heart.

“In that moment, I knew it could be done,” King says. He joined the staff of Ochsner Hospital immediately and set to work with Mills on developing the techniques and tools required to successfully repair holes inside a patient’s heart.

The first order of business was to raise funds to begin development of the device they would use. All the while, King and Mills faced another challenge. Before repairing any defect, they had to answer a simple question: how big was the hole?

To answer the second question, they began testing balloon catheters, which provided close approximations of a hole’s size. Within a millimeter or so, using just an inflatable balloon at the end of the catheter, a surgeon could estimate the size of the hole. With this challenge settled, next the team had to invent the device that would close the hole.

The device had to overcome several challenges. First, it had to be able to pass through the defect from one chamber of the heart into the other. It then had to deploy inside that other chamber in a configuration that would at once close the hole and prevent the device from retreating into the first chamber. Then, the device had to remain in place. All the while, it could be no larger than the end of the catheter that would deliver it–measured, like the defects it would repair, in millimeters.

King turned to a relative at Edwards Laboratory in Santa Ana, California. The laboratory was at the forefront of a new technology, Dacron, a thermoplastic polymer from the polyester family. With a high melting point, north of 200 degrees Celsius, Dacron could be combined with surgical stainless steel. It could also be sterilized and rendered medically safe. Fashioning an umbrella out of Dacron and stainless, the device could fit into the end of a surgical catheter for delivery.

Pushed through the end of the catheter, the folded umbrella would open. Working with Edwards, King developed a device that would retract the catheter until the umbrella was affixed to the outside of the defect, deploy the second umbrella against the defect, and then snap the two together. Easy, really, until the realization strikes that the physician is dealing with feel, deploying a quarter-sized device the weight of a small corner of tissue paper, inside a beating heart, at the end of a five-foot long spaghetti noodle cooked al dente. Nevertheless, after dozens of practice runs on canine research subjects, King had perfected the technique. “Once there, I’d jiggle it, make sure it was locked, and then detach it from the delivery system,” he says. “You had your heart patched, but not by opening your chest.”

Quickly, the team learned that the heart closed over the umbrella in a matter of months, incorporating the device into the very flesh of the heart. Dozens of experiments later, King was ready to try. They began searching for the perfect — and willing — test case.

Suzette Creppel didn’t want a scar. She was afraid of a major procedure. Complications were regular, and the recovery time was months, if not years, long.

“I would have had to have open heart surgery,” she says, emphasizing open and heart to underscore what that process meant. Years later, she would live through this moment again, albeit vicariously in the form of one of her children.

“My baby, my fourth one, my last one, was born with one of the things I had–the hole in my heart,” Creppel says. “But she also had the Epstein’s Anomaly.”

That diagnosis meant Creppel’s child would endure open heart surgery–heart bypass and all–and months of rehabilitation. The experience provided her with a glimpse of what might have occurred in that operating room in New Orleans back in 1975.

King and Mills were scrubbed and ready as their patient nodded off. In the anteroom, the secretary briefed the board. King had arrived that morning at 4 a.m., and by the time he asked for his scalpel, the excitement was palpable. “You could sense this in the air, that something was going to happen,” King says.

King and Mills couldn’t have asked for a better test subject. Creppel’s defect was 25 millimeters wide, nearly a perfect circle, and a 35 millimeter umbrella would close it. He knew the risks going in, and King understood that, at any moment, the order might be given to retract the catheter, step back, and watch as the patient was whisked into the adjoining operating room for open heart surgery. Adding to the pressure were the limitations of their device.

“Our device was not retractable. Once we had it out, it had to be in the right spot and work,” King says. “If it wasn’t, you were on your way to the OR to remove it.”

He inserted the catheter, confidently finding the defect, where he deployed the umbrella. A slight retraction, another deployment, a click. “You couldn’t tell it on the outside, but my heart was racing,” King says, estimating his pulse was north of 180. Then, came the moment of truth.

He jiggled the catheter, tugging on the umbrella. The device remained firmly in place. Later, John Chancellor and Walter Cronkite would trumpet the achievement on the evening news. In that moment, though, the staff and team at Ochsner were celebrating.

Between April and the end of 1975, Ochsner would deploy four more Mills-King devices, in patients ranging from 17 to 75. All patients did well and, with the exception of the 75 year-old patient, all are alive and well at the time of this writing. The oldest, now 85, phoned King on Christmas Eve to wish him a happy holiday. King has remained in touch with almost all of those early patients, including Creppel.
“He’s my hero,” Creppel tells BayouLife. “Out of all the doctors I’ve had, if it wasn’t for him, I probably wouldn’t be here today.”

King’s achievement aside, he notes today it wouldn’t be possible to create and deploy this device, no matter how beneficial. Controls and concerns for patient safety improve quality of care, but the moves also stifle innovation. Late last year, King broached the subject at a talk in Miami. The conference topic: disruptive thinking. King opened the conference and was followed in the podium by Alo Castenada, an infant heart surgeon, and Martin Elliot, the surgeon who pioneered the heart transplant. King’s message is clear.

“I could not do today what I did in those days,” he says. He stops short of criticizing the current system. “It depends on what you’re talking about. Is it protecting society? Yes and no.”
In the current state of modern medicine, developing a new drug routinely averages in costs of more than $100 million. The cost of developing and deploying his device in 1975: somewhere between $50,000 and $100,000. King is still hopeful for the future.

He’s recently discussed disruptive innovations with surgeons interested in completing pancreas transplants and geneticists interested in changing the course of lives for individuals with genetic defects by correcting problems at the cellular level. He foresees a day when physicians are able to genetically correct defects in fetuses at the unborn level. Any time he speaks to physicians and researchers about these other-worldly prospects, inevitably the answer on possibility is “yes.” In the near future, medicine may literally know no limits.

“I’ve said some pretty strange things in my career because I got away with some pretty strange things,” King says.

Since April 8, 1975, more than a million individuals have benefited from transcatheter ASD closure–known in textbooks as the Mills-King procedure. King continues to practice medicine today, and the cardiology clinic he founded in Monroe in the late 1970s was recently purchased by Ochsner Medical Center. For their achievement, Mills and King were nominated for the Nobel Prize in Physiology in 1976.