Heart: An American Medical Odyssey (24 page)

In 2001, about one in five patients who received a stent would develop restenosis similar to the vice president’s, and in most instances it was more an annoyance than a crisis. If Mr. Russert’s comment bothered the vice president, he didn’t show it. I was angry, but Cheney just laughed. I told Mr. Cheney that I was confident he would be fine and that I would tell him if I ever thought he was not capable of serving as vice president.

Over the next couple of days, the newspapers and broadcast media weighed in about Mr. Cheney’s fitness to serve.

The
Los Angeles Times
published an editorial:

Cheney comes across as an unflappable fellow, the sort who keeps a cool head and steady hand when the stress is great. . . . But daily stress and a very high workload of essential duties are not a prudent combination for a man with Cheney’s health history. Cheney’s doctor insisted he could be perfectly capable of finishing his term “in his fully vigorous capacity.” Yet there is a difference between vigor and capacity.

US News & World Report
speculated about who might replace the vice president:

White House officials concede there’s a contingency plan in case Cheney can’t continue in office. Bush confidants say any list of possible replacements would include Secretary of State Colin Powell, governors such as Pennsylvania’s Tom Ridge, and other Washington gray beards like Defense Secretary Donald Rumsfeld. In the meantime, Bush has barred aides from speculating because he considers it macabre.

Arianna Huffington wasn’t just ill informed; she was outright nasty:

The question remains: Is the vice president on a suicide mission—or just unable to overcome his type-A addiction to the adrenaline highs of his lofty position? After his last heart attack, he was asked if he was worried about having another one. “I don’t operate that way,” he replied. No, you just put the gun to your head and see if the next chamber is the one with the bullet.

After Mrs. Cheney arrived, the vice president changed into a suit, and Alan and I accompanied them to the entrance to the hospital where the motorcade was waiting. As we walked through the lobby, I stopped to allow Mr. Cheney to leave the hospital alone, but he paused and motioned to me to join him. A barrage of clicking camera shutters greeted us as we passed through the door. The vice president turned to shake my hand, and the photo of that moment made the front page of newspapers around the country.

•  •  •

Lew Hofmann arranged for Gary and me to return to the White House two weeks later. We planned to see the vice president in the residence clinic, and Lew met us at the gate and walked us over. As it would be a little while until the vice president arrived, we were told to make ourselves at home in Dr. Tubb’s office. Brigadier General Richard Tubb (also called Dick) had graduated from the Air Force Academy before going to medical school at the University of Wisconsin, and his office,
just a few steps from the elevator leading to the president’s quarters, contained a mix of mementos, including a classic doctor’s bag and a ceremonial sword, reflecting his dual careers as physician and military officer. While I waited, a medical unit staffer suggested that I look out the window. The ground-floor office faces the South Lawn, and just as I parted the drapes, I watched as Marine One, a green Sikorsky VH-3D helicopter, landed, returning President Bush to the White House.

When the vice president arrived, he looked well. He said that he had resumed exercising with a recumbent bike and elliptical trainer, and his weight was down a few pounds. Since the angioplasty two weeks earlier, there had been no chest pain, shortness of breath, or other symptoms. We spoke about the possibility that the stent could narrow again, and I told him that although there was a risk of that, I thought it was likely he would do well. During the press conference, I had quoted a 40 percent chance of restenosis, the textbook answer, but because Cheney’s specific lesion involved such a short segment of the stent, I thought it was probably half that. Mary Matalin had asked me about this a few days after the hospitalization, and I told her that I was intentionally lowering expectations, but I thought the vice president would do very well. Before the visit ended, I reminded the vice president that we still wanted him to wear a Holter monitor to continuously record his heart rhythm for twenty-four hours, and Lew said he would arrange for it.

•  •  •

In June, Lew obtained a Holter monitor (essentially a small recorder with a few EKG leads) from Bethesda Naval Hospital, and the vice president wore it over a weekend. During that interval, the monitor recorded quite a few isolated premature beats, a benign finding, but on two occasions four of these extra beats came one after another at a very fast rate, an ominous rhythm called ventricular tachycardia.

It had been known for many years that some patients with chronic heart disease die suddenly as a consequence of ventricular fibrillation (V Fib), essentially a chaotic electrical storm that causes the heart to quiver (fibrillate) ineffectively. In
2001 we knew that the risk of developing V Fib was inversely related to how well the heart contracts. A normal heart ejects about 60 percent of the blood that fills the left ventricle after each beat (ejection fraction 60 percent). The lower the ejection fraction (EF), the greater the risk of sudden cardiac death. The threshold for increased risk seemed to be around 35 percent, which is about what we estimated the vice president’s ejection fraction to be. Other risk factors for developing sudden cardiac death included a prior (resuscitated) cardiac arrest (which the vice president had never had) and the identification of ventricular tachycardia by Holter monitoring (which we had just found).

Mr. Cheney’s Holter monitor recorded more than 130,000 heartbeats over the thirty-four hours he wore it. Although only eight beats (.006 percent), lasting a total of about four seconds, were concerning, that was enough to identify the vice president as being at higher risk for a potentially fatal arrhythmia.

When we decided a couple of months earlier to have the vice president wear the monitor, a colleague had questioned the wisdom of the decision.

“Why look for trouble?” he asked.

To me, the answer was clear: sometimes what you don’t know can kill your patient. Now that we had the data, I knew that Vice President Cheney was going to need a defibrillator.

•  •  •

Mordechai Friedman, a Polish Jew, was born in Warsaw in 1924. When he was a teenager, his name was changed to Mieczyslaw (Michel) Mirowski in an attempt to shield him from the fierce anti-Semitism that would soon become genocide. On September 1, 1939, German troops invaded Poland, the opening act of World War II, and the beginning of a five-year brutal occupation that included the methodical murder of most of Poland’s Jewish population.
Of the 3.3 million Jews living in Poland prior to the war, only 350,000 would survive to see the war end.

Three months after the German invasion, Mirowski, sixteen years
old, left Warsaw, never to see his family again, and traveled east through wartime Soviet-occupied Poland, Uzbekistan, and the Ukraine.

After the war, he attended medical school in Lyon, France, and upon graduation went to Israel, where he worked for a while before moving to Mexico and the United States for training in cardiology. In 1963 he returned to Israel to practice cardiology and met Dr. Harry Heller, who would become his friend and mentor. Mirowski later said:

In 1966, my old boss, Professor Harry Heller, started having bouts of ventricular tachycardia. He was repeatedly hospitalized and treated with quinidine and procainamide (the leading antiarrhythmic drugs of the time). My wife asked me why I was so concerned. “Because he will die from it,” I told her. And he did, two weeks later while at dinner with his family.

Heller’s death prompted Mirowski to start thinking about solutions for sudden cardiac death. The 1960s saw the introduction of coronary care units, where high-risk patients were monitored and treated rapidly should a lethal arrhythmia, such as ventricular fibrillation, occur. Mirowski wondered whether the large defibrillators stationed in CCUs could be miniaturized and implanted like a pacemaker in an ambulatory patient. Mirowski said:

I talked to some cardiologists who knew more about such devices. They all told me that defibrillators couldn’t be miniaturized. In those days, a defibrillator weighed 30 to 40 pounds; it was preposterous to reduce it to the size of a cigarette box. But I had been challenged by the problem, initially because of the death of a man I admired very much, but also because people told me it couldn’t be done.

Mirowski moved his family to the United States in 1968 and accepted a job as the director of the CCU at Sinai Hospital, a community
hospital in Baltimore, where he met Dr. Morton Mower, with whom he would collaborate to build the world’s first implantable defibrillator. Mower later described the focus of the research:

The initial goal set was a battery operated, automatic defibrillating device to be tested in animals, capable of monitoring in a standby mode and recycling in the event more than a single shock would be required in a particular episode.

A defibrillator, which sits atop a hospital “crash cart,” contains a power source, usually a big battery that is continually charged through an AC outlet, a large capacitor, and the familiar paddles (now more commonly adhesive patches) that are used to transfer the energy to the patient for resuscitation. Before a defibrillator can deliver a shock, the capacitor must first be charged with several hundred joules of electricity, a process that takes several seconds. Crucially, Mirowski realized that a conventional defibrillator expends a lot of energy overcoming the resistance imposed by the skin and subcutaneous structures and that the heart could be defibrillated with much less energy if a shock was delivered from leads positioned inside the heart.

Mirowski and colleagues constructed prototypes, sometimes with components ordered from electronic catalogues and even scavenged from a camera flash. Soon they began laboratory tests on dogs. In 1972 Mirowski met Dr. Stephen Heilman, the CEO and founder of Medrad, a Pittsburgh-based manufacturer of angiographic injection devices. Heilman described his meeting with Mirowski:

More memorable for me was Michel himself. He was intense. His speech was enriched by the expressive movement of his eyes. I knew that he had had contact with several languages and peoples as a result of being Jewish and living in Europe during World War II. His dedication to the project particularly impressed me. . . . I sensed in him a deep intelligence and a dedication that stood out. By the end of lunch we had agreed to collaborate on this exciting idea.

There were those, however, who derided Mirowski’s implantable defibrillator, among them Dr. Bernard Lown, a world-famous cardiologist (and later winner of the Nobel Peace Prize), who more than a decade earlier had added greatly to the science of resuscitation with his significantly improved design for an external defibrillator. In a 1972 editorial in
Circulation
, the journal of the American Heart Association, written with Dr. Paul Axelrod, Lown wrote:

Experience teaches that a rigid solution to a biologic problem is usually no solution. If the patient with such an implanted device is found dead, numerous questions will loom including the gnawing doubt that electrocution may have been a factor. . . . In fact, the implanted defibrillator system represents an imperfect solution in search of a plausible and practical application. In the absence of a clearly defined clinical purpose, what then energizes such undertakings by a number of groups? The rationale for some current bioelectronic development is best exemplified by Edmund Hillary’s reasons for climbing Mt. Everest, “Because it was there.” The same holds for some electronic gadget manufacture: “It was developed because it was possible.”

Mirowski and colleagues responded to Lown’s criticism:

The authors” overcautious and negative attitude to the approach under investigation seems certainly premature at this experimental prototype stage. Would it not be more appropriate to postpone disqualification of this new way of approaching a major cause of mortality, however imperfect it may seem to be, until it faces the test of clinical trials?

Dr. Barry Maron, at the time a researcher at the National Heart Lung and Blood Institute, described Mirowski’s reception as “a
graphic illustration of the medical establishment against a guy who had no big name.”

Undeterred, Mirowski and colleagues continued their research, and on February 4, 1980, at Johns Hopkins Hospital in Baltimore, a fifty-seven-year-old woman with a prior heart attack and multiple episodes of sudden cardiac death requiring defibrillation received the world’s first implantable defibrillator. When the report of the initial implants was published in the
New England Journal of Medicine,
it was accompanied by an editorial with a decidedly different tone from Lown’s eight years earlier:

Although considerable additional work is needed to perfect the diagnostic and therapeutic capability of this device, it is a potentially important therapeutic contribution. . . . Viewed optimistically, this is yet another in an impressive series of contributions toward progress in the monitoring and identification of important ventricular arrhythmias and in their pharmacologic and electrical correction.

In 1985 the FDA approved the implantable defibrillator for commercial use. Since that time, millions of patients around the world have received the device during an outpatient procedure that takes about an hour and can be accomplished through a three-inch incision under the collarbone. Today implantable cardioverter defibrillators (ICDs) are used in patients who have survived cardiac arrest or those with high-risk features such as severely decreased heart function or certain inherited disorders.

•  •  •

On June 25, 2001, Gary and I went to the White House to discuss the results of the Holter monitor with the vice president. Lew arranged for us to meet in Dr. Tubb’s office, and we asked Dr. Sung Lee, a cardiac electrophysiologist with our group at George Washington, to join us. We told the vice president that the monitor recorded a few brief episodes of ventricular tachycardia, and in the context of his prior heart attacks and impaired left ventricular function, this finding identified him as being at higher risk of developing a potentially fatal arrhythmia.
I told the vice president that the risk could be reduced with the implantation of an ICD, and Sung described the procedure and the technology in great detail.