Gerard Houllier has suffered one of the nastiest heart problems imaginable.
Dissection of the aorta, the condition that struck him down during the half-time interval of the match against Leeds at Anfield on Saturday, is one of the most painful and dangerous afflictions known to medicine and poses an enormous challenge to the team at Broadgreen Hospital, Liverpool, looking after him. It requires emergency surgery of the highest skill and even then more than one-third of patients die.
Houllier came out of the operating theatre at 8am yesterday morning and was placed in intensive care on a ventilator. Over the next crucial 48 hours doctors will be checking first that the surgery has been a technical success and then that there is no damage to vital organs, including the brain, after the enormous trauma that the body has suffered from the condition and the surgery to correct it.
Dissection of the aorta is a rare affliction in which the aorta, the main vessel carrying blood from the heart around the body, is split in two along its length by the pressure of the blood being pumped out of the heart. It is sudden, immensely painful and immediately life-threatening. Some patients have described it as a ripping pain that travels down the back, from the chest to the belly.
It is worse and more dangerous than a heart attack, which is caused by a blood clot blocking one of the tiny coronary arteries that feed blood to the muscle of the heart. A heart attack is not treated with emergency surgery but with "clot-busting" drugs to dissolve the blood clot and get the blood flowing to the heart muscle again. Later, coronary bypass surgery may be carried out to replace the narrowed coronary arteries, which is now so commonly performed, and with such high success rates, it is almost routine.
That is not the case for dissection of the aorta. The United Kingdom's 35 cardiac surgery units carry out only a handful of emergency operations a year on patients with the condition. Bruce Keogh, consultant heart surgeon at Queen Elizabeth Hospital, Birmingham, and secretary of the Society of Cardiothoracic Surgeons, said: "This is a massive life-saving operation which is very demanding technically but it has been carried out in a big, well-respected cardiothoracic unit. It will be a very worrying time for Mr Houllier's family and for the whole team looking after him."
The operation involves draining all the blood from the heart and aorta while the circulation is taken over by a heart-lung machine. Normally, brain damage occurs if the brain is deprived of blood and oxygen for more than four minutes, so the body is cooled to 16C and the head packed with ice to extend the damage-free period to about 30 minutes.
This means the surgeons have to work fast, with a maximum of 30 minutes to conduct the necessary repairs. The aorta is composed of layers of tissue and a small tear in the inner layer results in some blood being forced between the layers which then tear apart under pressure. It usually starts about two centimetres beyond the heart and extends suddenly and rapidly to the belly button where the aorta branches to supply either leg.
The aim of the operation is to seal off the start of the tear, where the blood is entering, by cutting out four to six inches of the damaged aorta at the top and replacing it with a tube of waterproof, Dacron-like, material. This is sewn to the existing aorta and a special glue is used to seal the split blood vessel.
The surgeons will know quickly whether they have successfully sealed the tear in the aorta but it will be a day or two before they know how their patient has taken such an enormous assault. There may have been damage to branches of the aorta supplying the liver, kidneys and bowel that can result in temporary kidney failure and bowel problems. The biggest worry will be brain damage resulting from the interruption of the blood supply to the brain. However, most patients recover fully and resume a normal life.
Assuming all goes well, there is no reason why Houllier should not return to his job as Liverpool manager. At 54, he is young to have suffered the problem and, though he will be extremely weak for several weeks, he could be back at work in three months. He may have been unaware that he had high blood pressure and the stress of managing a Premier League side may have contributed to it. But provided he takes the medication necessary to control his blood pressure there is no reason why he should not lead his team to further triumphs.