Heart: An American Medical Odyssey (41 page)

Right away after the shock, the beat started. It was a nice beat, you know. When the heart is beating right, you’ve got a kind of screwing action. And you can immediately see that it’s all right. . . .

Then comes the moment when you stop the bypass. Now the heart is on for the first time, on its own. Now that heart’s got to do all the work for the body.

The news of the transplant rocketed around the world, and Christiaan Barnard became a worldwide celebrity.

•  •  •

Three days later, on December 6, 1967, Dr.
Adrian Kantrowitz became the first surgeon in the United States to perform a heart transplant and the first surgeon anywhere else in the world to perform the operation on a child when he transplanted the heart of an anencephalic baby into the body of two-and-a-half-week-old Jamie Scudero, an infant dying of a congenital heart defect called tricuspid atresia. The baby initially appeared to do well, with his heart rate and respiration near normal, but seven hours later, the heart suddenly stopped, and the child could not be resuscitated. Kantrowitz told the
New York Times
,
“We were trying to make one whole individual out of two individuals who did not have a chance for survival.” At his press conference, Kantrowitz credited Dr. Norman Shumway with developing the techniques used for the transplant operation. Kantrowitz also made sure people understood that he considered his first procedure a failure.

Two weeks later in Cape Town, on his eighteenth postoperative day, Louis Washkansky died from pneumonia, probably related to the strong immunosuppressive regimen of radiation, azathioprine, actinomycin C, and prednisone.

Shumway’s first transplant would come on January 6, 1968, when he placed the heart of a forty-three-year-old woman, who had died
from a cerebral hemorrhage, into the chest of a fifty-four-year-old retired steel worker suffering from congestive heart failure following a large myocardial infarction two years earlier. Shumway’s patient lived for fifteen days but died after a steady stream of complications.

A few days before Dr. Shumway’s initial transplant, Christiaan Barnard operated again.
This patient was Philip Blaiberg, whose surgery was a landmark in its own right. Not only did the fifty-eight-year-old dentist survive to be discharged from the hospital, he lived for another eighteen months, proof of the concept that a patient with a heart transplant could “return to life.” The operation pierced another barrier too: Blaiberg, who was white, had received the heart of Clive Haupt, a twenty-four-year-old man described as “colored” in the language of apartheid-era South Africa.

Dr. Blaiberg’s longevity helped to fuel explosive enthusiasm for heart transplantation. During the months following Christiaan Barnard’s first operation, 102 transplants were performed around the world, unfortunately often with dismal results, some by surgical teams unsuited for the demanding operation. Soon many of the groups would abandon cardiac transplantation.

Shumway persevered and continued to innovate, focusing on strategies to identify patients with rejection and new drugs to prevent it. In the first group of patients transplanted at Stanford University from 1968 to 1971, survival was 49 percent at six months and 30 percent at two years.

In the early years, EKG and echocardiographic changes were used to detect graft rejection, but in 1973, Shumway’s program began using endomyocardial biopsy, a safe and easy-to-accomplish procedure whereby a slim biopsy catheter is inserted via a needle stick in the neck and guided to the heart, and a tiny piece of myocardium retrieved for analysis by a pathologist. This technique allowed not only the early identification of rejection, but also the identification of patients in whom the doses of the powerful antirejection drugs might be decreased.

In 1980,
Dr. Shumway began using cyclosporin A, a new antirejection
drug isolated a decade earlier from a soil fungus, which was very effective in preventing rejection. By 1985, the five-year survival rates for patients undergoing cardiac transplantation had soared to 70 percent.

Norman Shumway died in 2006 at the age of eighty-three, leaving behind a remarkable legacy.
According to the United Network for Organ Sharing, in 2011, 21,457 adult heart transplant recipients were alive in the United States.

•  •  •

Mrs. Cheney had a party for the vice president when he finally made it home after getting his VAD. Too weak to walk more than a step or two, Mr. Cheney was assisted to a reclining chair in the master bedroom, and that is where we feted his homecoming. Mrs. Cheney served cake, and she had presents for the doctors and nurses who had cared for her husband. The occasion had the feel of a birthday party.

During the vice president’s long hospital stay, Mrs. Cheney had asked me if I was going to take my family on a summer vacation. I told her that I wouldn’t be going anywhere until the vice president was out of the hospital and that I would figure it out at that time. Now, in the second week of August, I still hadn’t given it much thought. As I stood in the bedroom munching on cake, Mrs. Cheney handed me an envelope, which contained a note and a key to their home in Jackson.

August 9, 2010

Dear Jonathan,

This is a present you have to give back, but only after you & your family have enjoyed Wyoming.

I can’t begin to express the enormous gratitude all Cheneys feel for the support & friendship you have been so generous with over the last month—and the last years. You have a special place in our heart and nothing will make us happier than thinking of you in Wyoming with your wonderful family.

At the end of August, Charisse and I took our daughters, Molly and Jamie, to Wyoming, where we rode horses, rafted the Snake, went to the rodeo, and hiked to a lake where we watched a moose drink from the cold mountain water. Cheney loved this place, its crisp air and jagged Teton skyline. It was easy to understand why. Before the vice president got the VAD, I had promised him he would see Jackson again, and although the summer had been rocky, with a little luck I would keep my word.

•  •  •

The hospitalization to implant the VAD had been an ordeal for the patient and his family. When Cheney was finally taken home by ambulance on August 9, 2010, he had been in the hospital for thirty-five days, the vast majority of that time in the intensive care unit, including a week on a respirator. There had been so much to contend with, including bleeding, a kidney injury, pneumonia, respiratory failure, and a pneumothorax (air leak from the lung), that the ICU director, Dr. Jason Vourlekis, at times looked like a plate spinner at a circus.

Vourlekis, whom I hadn’t known prior to the vice president’s hospitalization, is a very well trained pulmonary/critical care medicine physician who, prior to coming to Fairfax, had worked at National Jewish Medical and Research Center in Denver and the National Cancer Institute. He distinguished himself during the vice president’s complicated ICU stay and somehow managed to retain his dry sense of humor.

The hospitalization had also been hard on Cheney’s family. Mrs. Cheney, Liz, or Mary slept in the hospital almost every one of the nights he was hospitalized. When he was in the intensive care unit, a family member was with him 24/7, and on most days Gigi El-Bayoumi would come by to offer her irreplaceable counsel and endlessly compassionate ability to listen.

The vice president left the hospital about forty pounds lighter than when he went in, a consequence of his severe illness and many days without any oral nutrition. Unfortunately, the drop in weight also came at the expense of muscle mass. Cheney was going to require a lot
of rehab to regain the strength he had lost, not just during the hospital stay but also in the weeks of declining health leading up to the VAD.

Although the HeartMate II VAD is approved by the FDA for use as either a bridge to transplant or as destination therapy, some patients use it as a bridge to decision, giving them time to decide whether to pursue transplantation or to stick with the VAD. In the immediate aftermath of the vice president’s long hospitalization, the question of what to do next was really moot. In the near term, even if a heart were to become available unexpectedly, Cheney was in no condition to undergo another operation or, for that matter, even to decide whether he wanted a transplant. What did make sense was to get in line.

•  •  •

In the United States, organ transplantation is governed by a highly codified system of rules and procedures managed by UNOS (the United Network for Organ Sharing), a nonprofit organization that maintains the Organ Procurement and Transplantation Network, a unified transplant network established by Congress in 1984. UNOS manages the national transplant waiting list, develops the policies and procedures that govern organ allocation, and maintains a database that catalogues every transplant performed in the United States.

Each patient placed on the
heart transplant waiting list is assigned a status. Patients who have the highest urgency for transplant (the sickest) are called status 1A; these are patients on high-dose intravenous cardiac medications, those requiring ventilator support, and patients with VADs who are experiencing complications such as clots or infection. Patients in status 1B are those with VADs who are relatively stable, as well as the patients maintained on home intravenous infusions of cardiac medications. Status 2 patients are the least sick and don’t meet the criteria for status 1A or 1B.

Two days after the vice president’s surgery to implant the VAD, the transplant committee at Fairfax reviewed his case and wrote to him on July 12, 2010, informing him of their decision:

Dear Mr. Cheney

Following completion of your transplant evaluation, your case was recently presented to the Heart Transplant Committee for review. I am happy to report that you have been accepted for listing by the committee. You were listed on July 8, 2010.

Insurance authorization has been obtained and you are listed with UNOS (United Network for Organ Sharing) and your referring physician has been notified.

Attached is a letter from the United Network for Organ Sharing (UNOS). It describes the services and information offered to patients by UNOS and the Organ Procurement and Transplantation Network.

While waiting for your transplant, you will see Dr. Shashank Desai in the transplant clinic at Inova Fairfax Hospital. The frequency of those visits will be determined by your clinical condition.

If you get sick or are hospitalized while waiting for your heart transplant, it is your responsibility to ensure that the heart transplant program is notified. Changes in your condition may necessitate a change in your waiting status and therefore your position on the list.

Should questions arise prior to your next appointment, please feel free to contact us.

Sincerely

Carolyn Rosner, RN

Heart Transplant and Listing Coordinator

The Heart Transplant Program

Inova Fairfax Hospital

Entering the transplant queue obviously did not commit Mr. Cheney to receiving a heart, but it started the clock so that if and when he decided to pursue that option, he would have already accrued time.

•  •  •

I never intended the VAD to be a permanent solution for the vice president. Although Cheney was in his late sixties when his cardiac status began its precipitous slide, his noncardiac-related health was actually quite good. He had no sign of carotid disease and had never had a stroke, he did not have high blood pressure, there was no history of cancer or diabetes, and when his heart was working well, so were his kidneys. Cheney’s entire complicated and interlocking puzzle of medical problems was entirely due to his dying heart. The shortness of breath, fatigue, arrhythmias, DVT, renal function, bleeding, and swelling were the consequences of heart failure. If we could fix the heart, everything else would go away.

•  •  •

In spring 2010, as Mr. Cheney required multiple hospitalizations and the interludes of relative stability became shorter and shorter, I spoke with a colleague at GW involved in his care. It quickly became clear that the person he was worrying about was me.

“He’s dying, Jon, and there’s nothing you can do to stop that,” my colleague said.

“No, that’s not right,” I responded. “He can get a VAD, and then we’ll transplant him.”

“No, he can’t get a heart transplant,” he said slowly, as if he were trying to break the bad news to me gently.

“Yes, he can,” I said, and I walked away.

•  •  •

I viewed the VAD as a life raft for Cheney, not a destination. The boat was definitely sinking, but we were going to get off that boat, allow him enough time to rehabilitate, and give him time to work his way up the transplant list. That was the plan, and although he had told me early on that he was potentially interested in transplantation, he didn’t make his final decision until about six months after the VAD surgery when he was starting to feel well again.

Week by week, Cheney started to improve. The VAD can move a
lot of blood, and it provided the vice president with an essentially normal cardiac output. With reinvigorated blood flow, his kidney function returned to normal, as did his liver. The anorexia that accompanied his end-stage congestive heart failure dissipated, consequently improving his appetite and repleting his nutritional status. As Cheney’s metabolic parameters improved, his strength rebounded, and he was able to do more and more exercise.

In a letter to me on September 30, 2010, Shashank Desai wrote:

My impression is that Richard Cheney continues to improve nicely since implantation of his HeartMate II LVAD on July 6, 2010. I am happy to see how well he continues to recondition. I have encouraged him to increase his ambulation, and I am happy to see that he is actually traveling. Logistically, we have helped arrange delivery of oxygen to his high altitude locations, as well as ensuring he has backup batteries and controllers with him at all times. Arrangements have been made for a supply of dressings. Additionally, we have contacted the LVAD programs near to where he will be traveling.