Heart: An American Medical Odyssey (19 page)

I told Cheney that his symptoms concerned me, and I knew that to make a decision to come to the hospital on this particular night, he must have felt quite unwell. Furthermore, I noted that there were new abnormalities in the electrocardiogram, and coupled with the fact that his pain resolved promptly with the nitro, there likely was a new coronary lesion, but the only way to know for sure was to do a cath. At the time, Cheney’s cardiac enzymes were not yet available.

I outlined what we might find during the procedure. I told Cheney that his pain was likely coming from a narrowing in one of his “native” (original) coronary arteries. I knew this because a prior catheterization in 1995 had shown that two of his bypass grafts were closed, and the
EKG changes pointed toward involvement of a region of the heart no longer supplied by a graft. I said that if we found a blockage and if the vessel could be treated, we would repair it during the same procedure. I also told Cheney that it was possible, but not likely, that this was a false alarm. Finally, I stated that I thought it was important that we treat him the same way we treat every other patient who is admitted with a similar clinical presentation and not try to take any shortcuts.

It is commonly believed that VIPs receive better medical care than the general public. While it is true that connected people are often immunized from some of the annoying facets of modern American health care (waiting interminably for a call to be returned, being told that the next available appointment is six months away, or getting stuck in an ER for hours), there is a potential downside to being a celebrity.

In 1964, Walter Weintraub published an article, “The VIP Syndrome,” in which he described the hospital turmoil that frequently follows the admission of prominent or powerful patients and the
poor outcomes that sometimes ensue. Weintraub and others have noted that when a well-known person is admitted to a hospital, there is a tendency to consciously or unconsciously alter the care that is typically provided, and it often has negative consequences. For example, in an attempt to spare a VIP inconvenience or discomfort, fewer tests may be performed, or conversely, in a desire to leave no stone unturned, every conceivable test will be ordered. The department chief may be called, when in reality the better choice is a different, sometimes younger, physician who has more experience treating the problem at hand. Numerous specialists may be consulted, each told only what they need to know, creating silos of care. There is a tendency to place a VIP in a more luxurious or more discrete hospital location, apart from where treatment is usually rendered, and the treating physicians may avoid using the intensive care unit because of the perceived undesirable atmospherics, even when that setting might be preferable.

I had cared for hundreds of patients with the same clinical presentation as Mr. Cheney, and the recommendation to proceed with cardiac catheterization was the standard approach. In fact, one week before Cheney’s
hospitalization, a large clinical trial had validated this strategy, showing better outcomes in patients whose treatment included an early trip to the cath lab compared to those treated more conservatively. I told Cheney that I knew the cath might be politically awkward at that moment, but it was the correct thing to do, and I did not want political expediency to get in the way of doing what was right.

Mr. Cheney, who appeared remarkably calm, responded, “Nothing is more important,” and agreed that the cath made sense. It would be hard to imagine a more inconvenient time to undergo an invasive procedure, but if Cheney had any anxiety or reluctance to proceed, it didn’t show. I excused myself and left the room in order to make arrangements for the procedure.

In my absence, Mrs. Cheney asked Alan Wasserman, “Tell me, if this were you, would you let him perform this procedure?”

“As a matter of fact, I did.”

•  •  •

In November 1976, Andreas Gruentzig, a thirty-seven-year-old German-born physician, visited the United States to present his research at the annual scientific sessions of the American Heart Association (AHA). He had moved to Zurich in 1969 and became interested in vascular disease, at the time called “angiology.” Before that, the available methods for treating a narrowed leg vessel mostly involved surgical bypass or the less invasive Dotter technique, in which a series of increasingly larger-diameter rigid catheters were forced into the obstruction. Gruentzig understood that while this method could be effective in the large-caliber superficial femoral artery, which supplies blood to the leg, it could not work in small-diameter vessels and therefore would not be appropriate for use in the heart. Gruentzig had an idea to use a small inflatable balloon to crack open the obstruction, and he and his wife and some colleagues worked in his kitchen to develop a prototype. Because no such catheter existed anywhere,
Gruentzig had to develop all the components, making it small enough to deliver into an artery through
a puncture in the skin, with a way to inflate and deflate the balloon, and a balloon material strong enough to dilate the sometimes rigid and calcified plaques found in arteries.
Gruentzig and his team eventually developed a catheter with a resilient polyvinyl chloride (PVC) balloon mounted on its tip, and in January 1975 he used it to dilate a narrowing in a patient’s iliac artery, a large blood vessel in the pelvis.

A year and a half later at the AHA sessions, Gruentzig shared the results of his balloon technique adapted for use in the coronary arteries. The work, entitled “Experimental Percutaneous Dilatation of Coronary Artery Stenoses,” described experiments in dogs and was delivered as a poster to a group of somewhat doubtful colleagues. Dr. Spencer King III, who would later go on to become a renowned interventional cardiologist, president of the American College of Cardiology, and friend and colleague of Gruentzig, remembered seeing the presentation and thinking,
“this will never work.”

Gruentzig’s next step was to attempt his procedure, what is now called percutaneous transluminal coronary angioplasty (PTCA), in a live human heart. There are many considerations that go into planning a first-in-man procedure. What patient or lesion characteristics are ideal? Where should the procedure be performed? What could go wrong? The ideal patient would be someone with a relatively simple coronary narrowing suitable for treatment with a fairly crude, first-generation device. Because a lot could go wrong, Gruentzig decided to perform the first procedures in patients undergoing scheduled heart bypass surgery; should a major complication occur, it would happen in the very controlled environment of the cardiac operating room with a surgical team poised to react.

The risks were many. The inflated balloon could rupture the slender coronary artery, and if that occurred, blood would rapidly fill the pericardial space causing cardiac tamponade, a potentially fatal compression of the heart. During the dilation, fragments of atherosclerotic plaque could break off (embolize) and lodge downstream, blocking flow and precipitating a heart attack. The patient might not tolerate temporary
occlusion of the coronary artery and could develop a dangerous ventricular arrhythmia or cardiac arrest. The balloon might burst, becoming trapped in the vessel, or fail to deflate, causing a heart attack. Since this procedure had never before been performed in a human, there was no way to anticipate all the risks.

Although Gruentzig could not find a surgeon in Zurich who would allow him to perform coronary angioplasty during their surgery,
Dr. Elias Hanna, a cardiac surgeon in San Francisco, was amenable, and that is where Gruentzig successfully refined his technique prior to attempting the procedure in an awake patient not already destined for open heart surgery.

On September 16, 1977, Adolf Bachmann, a thirty-eight-year-old Swiss insurance salesman with severe chest pain, a tight narrowing in his left anterior descending coronary artery, and a strong desire to avoid cardiac surgery, was brought to Gruentzig’s cath lab in Zurich. Gruentzig later described the index procedure:

Early in the afternoon at a time when the anesthesiologist and the cardiac surgeon were available and no cardiac procedure was underway in the operating room, the patient came to our catheterization laboratory and was catheterized in the usual fashion. . . . The Chief of Cardiology, the cardiac surgeon, anesthesiologist, cardiology and radiology fellows were in the recording room to observe the procedure. The guiding catheter was placed in the left coronary orifice and the dilatation catheter was inserted. . . . The catheter wedged the stenosis so that there was no antegrade flow and the distal coronary pressure was very low. . . . To the surprise of all of us, no ST elevation, ventricular fibrillation or even extrasystole occurred and the patient had no chest pain. . . . After the first balloon deflation, the distal coronary pressure rose nicely. Encouraged by this positive response, I inflated the balloon a second time to relieve the residual gradient. Everyone was surprised about the ease of the procedure and I started to realize that my dreams had come true.

Several successful cases followed, and in November, Gruentzig presented a summary of his initial patients at the annual AHA meeting. Whereas one year earlier, his poster had been met with great skepticism, now his oral presentation was interrupted by a resounding standing ovation. Angioplasty and the field of interventional cardiology had been born, and physician and corporate interest in the new technique exploded.

Dr. Andreas Gruentzig and his wife, Margaret Anne, died on October 27, 1985, when the twin-engine Beechcraft Baron airplane he was flying crashed during a storm into a forest in Forsyth, Georgia.

Exactly ten years to the day after the world’s first coronary angioplasty, Gruentzig’s close friend and colleague, Dr. Spencer King III of Emory University, brought Adolph Bachmann back to the cath lab for a relook. The first coronary artery ever treated with balloon angioplasty was wide open.

Gruentzig was only forty-six years old when he died, but in his too-short life he changed medicine forever, and the technology he pioneered has touched the lives of millions of people.

•  •  •

Because of GW’s location just seven blocks from the White House and its close proximity to the Capitol and virtually every other federal department, contingency plans are always in place for care of the nation’s leadership, and GW Hospital has perhaps the only emergency room in the United States with a dedicated hotline to the Secret Service.

When Mr. Cheney arrived at the hospital, he was assigned an alias. His pseudonym, Red Adair, was not an attempt to hide his admission, which would have been impossible, but rather a standard procedure designed to help protect the privacy of his clinical data. (The real-life Paul “Red” Adair was a legendary Texas firefighter who became famous for putting out some of the world’s worst oilfield and offshore platform fires.) A Secret Service command post was set up in the hospital administration suite, and a large medical school auditorium across
Twenty-Third Street was configured as a media briefing room following the long-standing, prudent practice of keeping the press out of the hospital.

As the East Coast was waking to breaking news, Dick Cheney was being prepped for cardiac catheterization. Prior to transporting him to the cath lab, I did a walk-through with an agent from his Secret Service detail so he could plan the deployment of his personnel. The Secret Service did not post anyone in the procedure room itself; instead they positioned their agents in the control room and hallways surrounding the suite. Over the years, I have been asked many times to allow a patient’s family member, friend, or colleague to be present during a cath, but it’s distracting to have a visitor in the room, and I don’t allow it. I wouldn’t want anyone kibitzing with the pilots when they are landing the plane I’m on, and I extend that same courtesy to my patients while I am working inside their heart.

I gave the staff in the cath lab a brief pregame talk, reminding them that this was a procedure we did several times every day and I knew we would provide this patient the same great care we gave to everyone else. My team didn’t really need that reminder. I’m sure I intended it as much for myself as for them.

Cheney was transported by stretcher to the cath lab and helped onto the narrow padded table by Fernando Najera, a technologist, and Julia Mason, a nurse. I had met Fernando in 1990 on the first day of my cardiology fellowship, and he quickly became a friend. I’ve always admired his dedication to the care of patients with heart disease and his loyalty to GW. Fernando can do a surprisingly good rendition of the famous aria “Nessun Dorma,” and despite the vagaries of my morning mood, he can always make me smile. Julia came to GW in 1998 after working in a cath lab in Saudi Arabia while her husband, a US State Department official, was stationed there. There isn’t another health care professional with any title I have ever worked with whom I have relied on as much, or for whom I have more respect than Julia. The first thing I do every morning when I enter the cath lab is to check if Julia
is working that day. Every physician knows that it is the nurses who really keep patients alive, and if I ever get sick, I want Julia to take care of me.

After settling the patient on the table, Julia gave Mr. Cheney Versed, an intravenous Valium-like benzodiazepine, and fentanyl, a narcotic. The cocktail is called, somewhat incorrectly, “conscious sedation,” and it induces a sleepy, relaxed state with retrograde amnesia, the inability to remember what has just occurred. When I entered the room, Cheney appeared to be asleep, covered in a long, blue surgical drape, its two round circular cutouts exposing the skin of both groins.

I turned to my third-year cardiology fellow, Dr. Brian Rah, and handed him the needle.

“Really?” he said.

“Absolutely,” I replied.

I run an interventional cardiology training program in a university teaching hospital and perform all of my procedures with a cardiology fellow. This wasn’t the day to change my routine.

Brian easily entered the right common femoral artery, and together we advanced angiographic catheters to Cheney’s heart.